Comprehensive Formulary (List of Covered Drugs)

1 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLANHPMS Approved Formulary File Submission ID 22385, Version Number 06 This Formulary was updated on 10/01/2021. For more recent information or other questions, please contact Wellcare Member Services at the telephone number or website for your state listed on the inside front and back covers of this Formulary (List of Covered Drugs) Wellcare Assist (HMO) H9335006000 Plan in the following states: AL, CT, GA, IL, KY, LA, MI, MO, MS, NJ, NY, SC, TN, TX, WAWellcare Assist Compass (HMO), Wellcare Assist Open (PPO), Wellcare Community Assist (PPO)Plans in the following states: AR, CT, IL, LA, MA, ME, MI, MO, MS, NC, NH, NY, RI, VTWellcare Dual Access (HMO D-SNP) H9335003000, Wellcare Dual Access (HMO-POS D-SNP) Plans in the following states.

2 AL, AR, CT, FL, GA, KY, LA, ME, MI, MO, MS, NC, NY, TN, TX, WAWellcare Dual Access Extra (HMO-POS D-SNP), Wellcare Dual Access Open (PPO D-SNP)Plans in the following states: AL, AR, FL, GA, MI, MO, NY, OH, RI, TX, WAWellcare Dual Access Medicare (HMO D-SNP), Wellcare Dual Liberty (HMO-POS D-SNP)Plans in the following states: AR, NCWellcare Dual Freedom (HMO D-SNP), Wellcare Dual Liberty (HMO D-SNP) H5087027000 H1416036000 H4847004000, Wellcare Dual Liberty Freedom (HMO D-SNP), Wellcare Dual Liberty Open (PPO D-SNP)Plans in the following states: AL, CA, CT, FL, GA, KY, LA, ME, MS, NC, RI, SC, TX, WAWellcare Dual Pinnacle (HMO D-SNP), Wellcare Dual Reserve (HMO D-SNP), Wellcare Dual Select (HMO D-SNP), Wellcare Edge Plus (HMO), Wellcare Ohana Assist Open (PPO), Wellcare Ohana Dual Liberty (HMO D-SNP), Wellcare Ohana Plus (HMO), Wellcare Plus (HMO), Wellcare Plus Open (PPO)Plans in the following states.

3 CA, FL, HI, IL, LA, NH, VTY0020_WCM_72058E_FINAL_15_C Internal Approved 0709202110/01/2021 Wellcare 2021 NA2 WCMFOR77809E_CV15 CALIFORNIAHMO, HMO D-SNP1-866-999-3945 HAWAIIHMO, PPO, HMO D-SNP1-877-457-7621 ILLINOIS*HMO, HMO-POS, HMO C-SNP, PPO1-833-444-9088 GEORGIA, ILLINOIS**, INDIANA, MICHIGAN, OHIO AND SOUTH CAROLINA HMO, HMO C-SNP, HMO D-SNP, HMO-POS, HMO-POS C-SNP, HMO-POS D-SNP, PPO, PPO D-SNP 1-866-892-8340 ALL OTHER STATES HMO, HMO C-SNP, HMO-POS, HMO-POS C-SNP, PFFS, PPO1-833-444-9088 HMO D-SNP, HMO-POS D-SNP, PPO D-SNP1-833-444-9089 HOURS OF OPERATIONO ctober 1 to March 31: Monday Sunday, 8 to 8 1 to September 30: Monday Friday, 8 to 8 visit or * Wellcare Assist Compass (HMO), Wellcare Giveback Open (PPO), Wellcare No Premium (HMO-POS),Wellcare No Premium Open (PPO), Wellcare Patriot No Premium (HMO-POS), Wellcare Plus (HMO),Wellcare Specialty No Premium (HMO C-SNP)** Wellcare Assist (HMO), Wellcare Edge Plus (HMO), Wellcare No Premium Essential (HMO), Wellcare No Premium Exclusive (HMO)TTY FOR ALL OF THE ABOVE: 711We re Just aPhone Call Away10/01/2021 10/01/2021 I NA2 WCMFOR77809E_CV15 Note to existing members: This Formulary has changed since last year.

4 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 Assist (HMO), Wellcare Assist Compass (HMO), Wellcare Assist Open (PPO), Wellcare Community Assist (PPO), Wellcare Dual Access (HMO D-SNP), Wellcare Dual Access (HMO-POS D-SNP), Wellcare Dual Access Extra (HMO-POS D-SNP), Wellcare Dual Access Medicare (HMO D-SNP), Wellcare Dual Access Open (PPO D-SNP), Wellcare Dual Freedom (HMO D-SNP), Wellcare Dual Liberty (HMO D-SNP), Wellcare Dual Liberty (HMO-POS D-SNP), Wellcare Dual Liberty Freedom (HMO D-SNP), Wellcare Dual Liberty Open (PPO D-SNP), Wellcare Dual Pinnacle (HMO D-SNP), Wellcare Dual Reserve (HMO D-SNP), Wellcare Dual Select (HMO D-SNP), Wellcare Edge Plus(HMO)

5 , Wellcare Ohana Assist Open (PPO), Wellcare Ohana Dual Liberty (HMO D-SNP), Wellcare Ohana Plus (HMO), Wellcare Plus (HMO), Wellcare Plus Open (PPO).This document includes a list of the drugs ( Formulary ) for our plan which is current as of 10/01/2021. 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, 2022, and from time to time during the is the Wellcare Assist (HMO), Wellcare Assist Compass (HMO), Wellcare Assist Open (PPO), Wellcare Community Assist (PPO), Wellcare Dual Access (HMO D-SNP), Wellcare Dual Access (HMO-POS D-SNP), Wellcare Dual Access Extra (HMO-POS D-SNP), Wellcare Dual Access Medicare (HMO D-SNP), Wellcare Dual Access Open (PPO D-SNP), Wellcare Dual Freedom (HMO D-SNP), Wellcare Dual Liberty (HMO D-SNP),Wellcare Dual Liberty (HMO-POS D-SNP), Wellcare Dual Liberty Freedom (HMO D-SNP), Wellcare Dual Liberty Open (PPO D-SNP), Wellcare Dual Pinnacle (HMO D-SNP)

6 ,Wellcare Dual Reserve (HMO D-SNP), Wellcare Dual Select (HMO D-SNP), Wellcare Edge Plus (HMO), Wellcare Ohana Assist Open (PPO), Wellcare Ohana Dual Liberty(HMO D-SNP), Wellcare Ohana Plus (HMO), Wellcare Plus (HMO), Wellcare Plus Open(PPO) 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 II Can the Formulary ( drug list) change?

7 Most changes in drug coverage happen on January 1, but we 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. C hanges that can affect you this year: In the below cases, you will be affected by coverage changes during the year: N e w generic drugs. We may immediately remove a brand name drug on our drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost-sharing tier and withthe same or fewer restrictions. Also, when adding the new generic drug , we may decide to keep thebrand name drug on our drug List, but immediately move it to a different cost-sharing tier or addnew restrictions.

8 If you are currently taking that brand name drug , we may not tell you in advancebefore we make that change, but we will later provide you with information about the specificchange(s) we have we make such a change, you or your prescriber can ask us to make an exception and continueto cover the brand name drug for you. The notice we provide you will also include information onhow to request an exception, and you can find information in the section below titled How do Irequest an exception to the Wellcare Assist (HMO), Wellcare Assist Compass (HMO), WellcareAssist Open (PPO), Wellcare Community Assist (PPO), Wellcare Dual Access (HMO D-SNP),Wellcare Dual Access (HMO-POS D-SNP), Wellcare Dual Access Extra (HMO-POS D-SNP),Wellcare Dual Access Medicare (HMO D-SNP), Wellcare Dual Access Open (PPO D-SNP),Wellcare Dual Freedom (HMO D-SNP), Wellcare Dual Liberty (HMO D-SNP), Wellcare DualLiberty (HMO-POS D-SNP), Wellcare Dual Liberty Freedom (HMO D-SNP), Wellcare Dual LibertyOpen (PPO D-SNP)

9 , Wellcare Dual Pinnacle (HMO D-SNP), Wellcare Dual Reserve (HMO D-SNP),Wellcare Dual Select (HMO D-SNP), Wellcare Edge Plus (HMO), Wellcare Ohana Assist Open(PPO), Wellcare Ohana Dual Liberty (HMO D-SNP), Wellcare Ohana Plus (HMO), Wellcare Plus(HMO), Wellcare Plus Open (PPO) s Formulary ? D r ugs removed from the market. If the Food and drug Administration deems a drug on ourformulary to be unsafe or the drug s manufacturer removes the drug from the market, we willimmediately remove the drug from our Formulary and provide notice to members who take thedrug. Other c hanges. We ma y make other changes that affect members currently taking a drug . Forinstance, we may add a generic drug that is not new to market to replace a brand name drugcurrently on the Formulary ; or add new restrictions to the brand name drug or move it to a differentcost sharing ti er or both.

10 Or we may make changes based on new clinical guidelines. If we removedrugs from our Formulary , or add prior authorization, quantity limits and/or step therapy restrictionson a drug or move a drug to a higher cost-sharing tier, we must notify affected members of thechange at least 30 days before the change becomes effective, or at the time the member requests arefill of the drug , at which time the member will receive a 30-day supply of the III oIf we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled How do I request an exception to the Wellcare Assist (HMO), Wellcare AssistCompass (HMO), Wellcare Assist Open (PPO), Wellcare Community Assist (PPO), Wellcare DualAccess (HMO D-SNP), Wellcare Dual Access (HMO-POS D-SNP), Wellcare Dual Access Extra(HMO-POS D-SNP), Wellcare Dual Access Medicare (HMO D-SNP), Wellcare Dual Access Open(PPO D-SNP), Wellcare Dual Freedom (HMO D-SNP), Wellcare Dual Liberty (HMO D-SNP),Wellcare Dual Liberty (HMO-POS D-SNP), Wellcare Dual Liberty Freedom (HMO D-SNP),Wellcare Dual Liberty Open (PPO D-SNP)