2021 Comprehensive Formulary (List of Covered Drugs)

1 Comprehensive Formulary 2021. (List of Covered Drugs). WellCare Access (HMO D-SNP), WellCare Access (HMO-POS D-SNP), WellCare Compass (HMO), WellCare Edge (HMO), WellCare Extra Plus (HMO-POS D-SNP), WellCare Freedom (HMO D-SNP), WellCare Imperial (PPO D-SNP), WellCare Pinnacle (HMO D-SNP), WellCare Plus (HMO), WellCare Plus (PPO), WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO). Plans in the following states: AL, AR, AZ, CA, CT, FL, GA, IL, IN, KY, LA, ME, MI, MO, MS, NC, NH, NJ, NY, OH, RI, SC, TN, TX, VT, WA. WellCare Dividend (HMO). Plan in the following states: MI, OH. WellCare Essential (HMO) H5779005000. Plan in the following state: IL. WellCare Liberty (HMO D-SNP), WellCare Liberty (HMO-POS D-SNP). Plans in the following states: AL, AR, AZ, FL, GA, KY, LA, ME, MS, NY, TX, WA. PLEASE READ: This document contains information about the drugs we cover in this plan.

2 HPMS Approved Formulary File Submission ID 21392, Version Number 18. This Formulary was updated on 12/01/2021. For more recent information or other questions, please contact WellCare at the telephone number listed on the inside front and back covers of this Formulary , or visit Y0070_WCM_56007E_FINAL_08_C Internal Approved 07282020. 12/01/2021 WellCare 2020 NA1 WCMFOR70361E_CV08. We're Always Just a Phone Call Away! If you're ready to enroll or have enrollment questions, call 1-866-527-0056, or call 1-866-907-2058 (Hawaii). Representatives are available from 8 to 8 , 7 days a week. If you're already a member, call the Customer Service number for your state/plan listed below. California HMO, HMO D-SNP 1-866-999-3945. Hawaii HMO, HMO D-SNP 1-877-457-7621. HMO, HMO-POS, Illinois* 1-833-444-9088. HMO C-SNP, PPO. HMO, HMO-POS, Georgia, Illinois**, Indiana, HMO-POS D-SNP, HMO C-SNP, Michigan, Ohio and 1-866-892-8340.

3 HMO D-SNP, HMO-POS C-SNP, South Carolina PPO, PPO D-SNP. Texas** HMO 1-866-230-2513. HMO, HMO C-SNP, 1-833-444-9088. HMO-POS, PPO. All Other States HMO D-SNP, HMO-POS D-SNP, 1-833-444-9089. PPO D-SNP. Hours of operation Between October 1 and March 31, representatives are available Monday Sunday, 8 to 8 , Between April 1 and September 30, representatives are available Monday Friday, 8 to 8 , or visit us anytime at or TTY for all of the above ..711. * Illinois Applicable Plan Names: WellCare Absolute (PPO), WellCare Compass (HMO), WellCare Guardian (HMO C-SNP), WellCare Patriot (HMO-POS), WellCare Plus (HMO), WellCare Premier (PPO), WellCare Value (HMO-POS). ** Illinois Applicable Plan Names: WellCare Edge (HMO), WellCare Essential (HMO), WellCare Essential (HMO-POS), WellCare Exclusive (HMO), WellCare Explore (HMO-POS).

4 **Texas Applicable Plan Name: City of Houston Group Retirees (HMO). 12/01/2021. Note to existing members: This Formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list ( Formulary ) refers to we, us or our, it means WellCare. When it refers to plan or our plan, it means WellCare Access (HMO D-SNP), WellCare Access (HMO-POS D-SNP), WellCare Compass (HMO), WellCare Dividend (HMO), WellCare Edge (HMO), WellCare Essential (HMO), WellCare Extra Plus (HMO-POS D- SNP), WellCare Liberty (HMO D-SNP), WellCare Liberty (HMO-POS D-SNP), WellCare Freedom (HMO D-SNP), WellCare Imperial (PPO D-SNP), WellCare Pinnacle (HMO D-SNP), WellCare Plus (HMO), WellCare Plus (PPO), WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO).

5 This document includes a list of the drugs ( Formulary ) for our plan which is current as of 12/01/2021. For an updated Formulary , please contact us. Our contact information, along with the date we last updated the Formulary , appears on the inside front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, Formulary , pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year. What is the WellCare Access (HMO D-SNP), WellCare Access (HMO-POS D-SNP), WellCare Compass (HMO), WellCare Dividend (HMO), WellCare Edge (HMO), WellCare Essential (HMO), WellCare Extra Plus (HMO-POS D-SNP), WellCare Liberty (HMO D-SNP), WellCare Liberty (HMO-POS D-SNP), WellCare Freedom (HMO D-SNP), WellCare Imperial (PPO. D-SNP), WellCare Pinnacle (HMO D-SNP), WellCare Plus (HMO), WellCare Plus (PPO), WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO).

6 Comprehensive Formulary ? A Formulary is a list of Covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our Formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but our plan may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes.

7 Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you.

8 The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled How do I request an exception to the WellCare Access (HMO D-SNP), WellCare Access (HMO-POS D-SNP), WellCare Compass (HMO), WellCare Dividend (HMO), WellCare Edge (HMO), WellCare Essential (HMO), WellCare Extra Plus 12/01/2021 I NA1 WCMFOR70361E_CV08. (HMO-POS D-SNP), WellCare Liberty (HMO D-SNP), WellCare Liberty (HMO-POS D-SNP), WellCare Freedom (HMO D-SNP), WellCare Imperial (PPO D-SNP), WellCare Pinnacle (HMO D-SNP), WellCare Plus (HMO), WellCare Plus (PPO), WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO) Formulary ? . Drugs removed from the market. If the Food and Drug Administration deems a drug on our Formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our Formulary and provide notice to members who take the drug.

9 Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the Formulary ; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our Formulary , or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you.

10 The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled How do I request an exception to the WellCare Access (HMO D-SNP), WellCare Access (HMO-POS D-SNP), WellCare Compass (HMO), WellCare Dividend (HMO), WellCare Edge (HMO), WellCare Essential (HMO), WellCare Extra Plus (HMO-POS D-SNP), WellCare Liberty (HMO D-SNP), WellCare Liberty (HMO-POS D-SNP), WellCare Freedom (HMO D-SNP), WellCare Imperial (PPO D-SNP), WellCare Pinnacle (HMO D-SNP), WellCare Plus (HMO), WellCare Plus (PPO), WellCare Reserve (HMO D-SNP), WellCare Select (HMO D-SNP), WellCare Summit (PPO) Formulary ? . Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 Formulary that was Covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above.