PRO_27552E Internal Approved 01082019
©WellCare 2018 NA8CADLTR27552E_0000
06/13/2019Dear Provider,
At the June 13, 2019 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes would be made to the Kentucky Medicaid Preferred Drug List (PDL).
They will be effective 08/27/2019. Please review these changes carefully.
Key
UPPER CASE = Brand Name Drugs QL = Quantity Limit Lower case italics = Generic Drugs ST = Step Therapy PDL = Preferred Drug List AL = Age Limit PA = Prior Authorization YOA = Years of Age SC = Safety Concerns LU = Low Utilization PC = Pharmacoeconomic Considerations DD = Discontinued Drug GA = Generic Available
Effective date of change: 08/27/2019
Drug Name Therapeutic Class Change PDL Alternative (if applicable) ADDITIONS TO THE PDL
acidophilus/pectin Antidiarrheals Added to the PDL
UTILIZATION MANAGEMENT CHANGESfluocinolone
acetonide 0.01 % solution
Dermatologicals QL Updated:
QL: 120 ml / 30 Days
fluocinonide 0.05 % cream
Dermatologicals QL Updated:
QL: 120 gm/ 30 days
The changes below are general updates. They will go into effect on 07/15/2019:
REMOVALS FROM THE PDL DULERA 100/5 MCG
and 200/5MCG
Antiasthmatics Removed from the PDL/PC
WIXELA 100- 50MCG, 250-50 MCG, and
500/50MCG (QL:
60 each /30days);
UPDATE
Kentucky Medicaid
Preferred Drug List
PRO_27552E Internal Approved 01082019
©WellCare 2018 NA8CADLTR27552E_0000 ANORO ELLIPTA 62.5-25MCG (QL:
60 each /31 days);
COMBIVENT RESPIMAT 20- 100MCG (QL: 4gm /20 days)
SYMBICORT 80- 4.5MCG and 160- 4.5MCG
Antiasthmatics Removed for ages 13 YOA and older from the PDL/PC
WIXELA 100- 50MCG, 250-50 MCG, and
500/50MCG (QL:
60 each /30days);
ANORO ELLIPTA 62.5-25MCG (QL:
60 each /31 days);
COMBIVENT RESPIMAT 20- 100MCG (QL: 4gm /20 days)
If you have any questions, WellCare’s Pharmacy Help Desk is available to assist providers at 1-877-389-9457.
Thank you for your care of WellCare’s Kentucky Medicaid members.
Sincerely,
WellCare Health Plans, Inc.
