acidophilus/pectin Antidiarrheals Added to the PDL

PRO_27552E Internal Approved 01082019

©WellCare 2018 NA8CADLTR27552E_0000

Dear Provider,

At the June 13, 2019 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes would be made to the WellCare’s South Carolina Medicaid Preferred Drug List (PDL). They will be effective

08/27/2019

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

fluocinolone

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

South Carolina Medicaid

Preferred Drug List

PRO_27552E Internal Approved 01082019

©WellCare 2018 NA8CADLTR27552E_0000

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)

Below are changes to the Medication Assisted Treatment (MAT) medications.

Effective as of April 2019.

Drug Name Therapeutic Class Change PDL

Alternative (if applicable) ADDITIONS TO THE PDL

VIVITROL 380mg Analgesics - Opioid Added to the PDL QL:1 vial / 28 days AL: Minimum 18 YOA

SUBOXONE SL

Tablet 2‐0.5 MG

Analgesics - Opioid PA Removed QL: 360 tablets / 30 days (12 tablets / 1 day) AL: Minimum 16 YOA SUBOXONE SL

Tablet 8‐2 MG

Analgesics - Opioid PA Removed

QL: 90 tablets / 30 days (3 tablets / 1 day)

AL: Minimum 16 YOA SUBUTEX SL Tablet

2 MG

Analgesics - Opioid PA Removed

QL: 360 tablets / 30

days (12 tablets / 1 day)

AL: Minimum 16 YOA

PRO_27552E Internal Approved 01082019

©WellCare 2018 NA8CADLTR27552E_0000 SUBUTEX SL Tablet

8 MG

Analgesics - Opioid PA Removed

QL: 90 tablets / 30 days (3 tablets / 1 day)

AL: Minimum 16 YOA

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 WellCare’s South Carolina Medicaid members.

Sincerely,

WellCare Health Plans, Inc.