CurrentmhnPolicy 25-1289 (12/25)

Formulary alternatives for non‑covered medications

Lists common medications that are not covered by the Plan and the Plan's preferred covered alternatives, including any formulary restrictions; intended for providers and pharmacists serving Wellcare By Health Net members.

Policy Summary

Payermhn

PolicyFormulary alternatives for non‑covered medications

Policy CodePolicy 25-1289 (12/25)

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionVerify prior authorization (PA) and quantity limits (QL) on the Plan formulary before prescribing covered alternatives.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40,000+medications covered by the Plan (general statement)

Multiple biologicstypes of medications listed with alternatives

10/01/2025information correct as of

PA / QLformulary restrictions noted

Covered Alternatives and Scope

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Prescriber and Pharmacy Actions

Prior Authorization

Prior Authorization / Quantity Limit Requirements

Some covered alternatives are subject to Prior Authorization (PA) and/or Quantity Limits (QL). Verify PA and QL requirements on the Plan formulary prior to prescribing or dispensing to avoid delays or denials.

Check the member's plan formulary and PA/QL lookup tools before prescribing.
PA and QL may apply even when an interchangeable (**) alternative is available.

Denial Risk

Formulary Restriction Triggers

Coverage of alternative medications may be restricted by formulary rules such as Prior Authorization or Quantity Limits. Lack of an approved PA or exceeding a QL may result in claim denial or member cost-sharing.

Formulary restriction triggers include: PA, QL, and plan-specific step therapy requirements.
When an alternative is listed with a Formulary restrictions = PA or QL, obtain prior authorization or ensure the dispensed quantity is within the allowed limit.

Documentation Required

Prescribing and Verification Note

Medications marked with a double asterisk (**) are interchangeable alternatives with the same active ingredient as the non-covered medication. If the member has an active prescription for a non-covered medication, providers and pharmacies may substitute the double-asterisk (**) alternative without requiring a new prescription when state law and plan rules allow.

Confirm the member has an active prescription for the non-covered product before substituting the (**) alternative.
Document the substitution in the patient chart and on the pharmacy claim as required by the plan.

Step Therapy

Preferred Alternatives Guidance

Preferred alternatives listed in the formulary are suggested first-line options and may be required as a step before coverage of certain non‑preferred agents. When a preferred alternative is available (including interchangeable ** products), consider prescribing the preferred agent to meet step-therapy requirements and minimize authorization needs.

Use the listed preferred alternative(s) before requesting coverage for a non-preferred product when step therapy applies.
If a patient has clinical reasons why a preferred alternative is inappropriate, include supporting documentation with the PA request.

Policy Background

This summary identifies covered substitutes across multiple therapeutic areas (for example, insulin products, inhaled corticosteroid/long‑acting beta‑agonist combinations, migraine agents, and biologics). Some listed alternatives are noted with formulary restrictions such as Prior Authorization (PA) and Quantity Limits (QL), and certain biologic reference agents (e.g., HUMIRA, STELARA) have biosimilar alternatives listed. If a member is already taking a non‑covered medication, an interchangeable alternative marked with a double asterisk (**) may be dispensed without a new prescription when applicable; regardless, always check the current formulary for PA/QL and coverage details before dispensing.

Key Definitions

** (double asterisk) — Definition and dispensing note

DefinitionDouble asterisk (**) indicates an interchangeable alternative with the same active ingredient that can be dispensed without a new prescription if the member has an active prescription for the non-covered medication.

When it appliesApplies when a covered alternative is marked with ** next to the drug name in the formulary alternatives list.

Provider actionVerify the member has an active prescription for the non-covered medication before dispensing the ** alternative without a new prescription.

Verification reminderAlways check the current Plan formulary for any PA or QL that may still apply to the alternative even if it is interchangeable.

Non‑covered medication	Preferred/formulary alternative(s)	Formulary restrictions
BASAGLAR (insulin glargine) / TRESIBA (insulin degludec) / INSULIN DEGLUDEC [discontinued] / SEMGLEE (insulin glargine‑yfgn)** / LANTUS (insulin glargine) / INSULIN GLARGINE
Medication(s) covered on the formulary = INSULIN GLARGINE‑YFGN**, INSULIN GLARGINE U‑300
Formulary restrictions = None

Quantity Limits and Related Notes

Multiple listed alternatives — Quantity Limits (QL) guidance

ScopeMultiple non‑covered medications list one or more covered alternatives; many alternatives include explicit Formulary restrictions (PA and/or QL).

Quantity limits noteQuantity Limits (QL) are indicated for specific alternatives in the list (e.g., ADVAIR DISKUS → QL; SYMBICORT → QL; PULMICORT FLEXHALER → QL).

Examples with QLExamples where QL is noted: BYDUREON BCISE (covered alternatives MOUNJARO/OZEMPIC etc.) = PA, QL; XULTOPHY → QL; GEMTESA → QL; TRULANCE → QL.

Actionable checkBefore prescribing or dispensing a listed alternative, verify the Plan formulary for any PA and QL that apply to that specific alternative and follow PA/QL processes as required.

Biosimilar Alternatives

Billing Rule

HUMIRA — covered biosimilars listed; PA/QL apply

Biosimilar adalimumab products (CYLTEZO, YUFLYMA, STEQEYMA) are listed as covered alternatives to HUMIRA (adalimumab) and are noted with formulary restrictions including PA and QL.

Reference drug: HUMIRA (adalimumab); covered biosimilars: CYLTEZO (adalimumab-adbm), YUFLYMA (adalimumab-aaty), STEQEYMA
Formulary restrictions for HUMIRA alternatives = PA, QL

Billing Rule

STELARA — STEQEYMA listed as covered biosimilar; PA/QL apply

STEQEYMA (ustekinumab‑stba) is listed as a covered alternative to STELARA (ustekinumab); formulary restrictions for STELARA alternatives include PA and QL.

Reference drug: STELARA (ustekinumab); covered biosimilar: STEQEYMA (ustekinumab-stba)
Formulary restrictions for STELARA alternatives = PA, QL

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