CurrentmhnPolicy 25-1289 (12/25)

Formulary common non-covered medications and covered alternatives (Wellcare / Health Net)

List of commonly prescribed medications that are not covered by the Plan alongside suggested covered alternatives and any formulary restrictions (e.g., PA, QL). Intended as a quick-reference for providers and members to identify alternatives and note restrictions; not a complete formulary.

Policy Summary

Payermhn

PolicyFormulary common non-covered medications and covered alternatives (Wellcare / Health Net)

Policy CodePolicy 25-1289 (12/25)

Change TypeNo material change

Effective Date

Next Review Date

Key ActionConfirm coverage and any restrictions (PA, QL) by checking the current Plan formulary; the document is a summary and may not reflect all restrictions.

POLICY UPDATE CHANGES

No material clinical/coverage changes — the brief provides a summary list of non-covered medications and suggested covered alternatives but has no listed policy changes.

~40,000Medications covered by Plan (stated)

multipleListed non-covered medications with alternatives

severalAlternatives with PA

severalAlternatives with QL

Policy summary and scope

Scope: This quick-reference lists commonly prescribed medications that are not covered by the Plan alongside suggested covered alternatives and any formulary restrictions (e.g., PA, QL). Coverage stance: mixed. Confidence: 0.55. Policy: 25-1289 (12/25); Subject: Formulary common non-covered medications and covered alternatives (Wellcare / Health Net); Status: CURRENT. Brief stats snapshot: Plan covers ~40,000 medications; the summary lists multiple non-covered medications with alternatives, with several alternatives subject to PA and several subject to QL. Background note: this summary lists common non-covered medications and recommended covered alternatives; uses ** for interchangeable alternatives; not a complete formulary.

Policy Number25-1289 (12/25)

SubjectFormulary common non-covered medications and covered alternatives (Wellcare / Health Net)

PayerWellcare / Health Net

StatusCURRENT

Last review2025-10-01

Next review

Confidence0.55

Coverage mapping and restrictions

Clarifying note: Symbols matter — the double asterisk (**) denotes an interchangeable alternative (same active ingredient) that may be accessed without a new prescription if the member already has an active prescription. This document is a summary and not the complete formulary; always verify the current Plan formulary for authoritative, up-to-date coverage and restriction details.

Actions for prescribers and billers

Documentation Required

Check current formulary

Confirm coverage and any restrictions (PA, QL) by checking the current Plan formulary; the document is a summary and may not reflect all restrictions.

Verify whether listed alternatives require prior authorization (PA) or have quantity limits (QL).
This is a summary only — always consult the Plan formulary for complete, current restrictions.

Prior Authorization

Prior authorization may be required

Several listed alternatives have PA indicated. Providers must obtain prior authorization when the formulary indicates PA.

BYDUREON BCISE alternatives (e.g., MOUNJARO, OZEMPIC, RYBELSUS, TRULICITY) — PA indicated
FASENRA alternatives (e.g., DUPIXENT, XOLAIR) — PA indicated
REPATHA alternative PRALUENT — PA indicated
AJOVY alternatives AIMOVIG/EMGALITY — PA indicated
ACTEMRA alternatives (tocilizumab biosimilars and other listed biologics) — PA indicated
HUMIRA alternatives (adalimumab biosimilars and other listed biologics) — PA indicated
STELARA alternatives (ustekinumab biosimilar STEQEYMA and others) — PA indicated
AUSTEDO alternatives (e.g., INGREZZA, tetrabenazine) — PA indicated
Abiraterone acetate 250 mg alternative to 500 mg — PA indicated
EPOGEN/PROCRIT alternative RETACRIT — PA indicated
OPSUMIT alternatives (e.g., sildenafil, tadalafil, ambrisentan, bosentan) — PA indicated

Billing Rule

Quantity limits

Some alternatives are subject to quantity limits (QL) as indicated; providers should follow the formulary QL rules when prescribing.

Some listed alternatives (e.g., BYDUREON BCISE alternatives, XULTOPHY, ADVAIR DISKUS alternatives, fluticasone-salmeterol products) are noted with QL.
Follow the Plan formulary QL rules for any alternative that indicates a quantity limit.

Terms and background

Background: This is a quick-reference list of common non-covered medications and suggested covered alternatives for Wellcare by Health Net. It highlights which alternatives are on the formulary and notes any formulary restrictions such as PA (prior authorization) or QL (quantity limits). Medications marked with ** are interchangeable alternatives (same active ingredient). The list is intended as a helpful guide but is not a complete formulary — always check the current Plan formulary for full, authoritative coverage and restriction information.

Term	Definition
{"text":"**","status":""},{"text":"Interchangeable alternative (same active ingredient); accessible without a new prescription if member has an active prescription for the non-covered medication.","status":""}
{"text":"PA","status":""},{"text":"Prior authorization","status":""}
{"text":"QL","status":""},{"text":"Quantity limit","status":""}