Dear Provider:

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NY028302_PRO_LTR_ENG Internal Approved 12152014 63821

09/21/2017

Dear Provider:

At the September 21,2017 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to WellCare’s New York Medicaid Preferred Drug List (PDL), effective 12/05/2017. Please carefully review these changes.

Key

UPPER CASE = Brand Name Drugs PA = Prior Authorization

Lower case italics = Generic Drugs

QL = Quantity Limits PDL = Preferred Drug List ST = Step Therapy YOA = Years of Age AL = Age Limit

SC = Safety Concerns LU = Low Utilization PC = Pharmacoeconomic Considerations DD = Discontinued Drug GA = Generic Available

Effective date of change: 12/05/2017

Drug Name Therapeutic Class Change/Reason for Change

PDL Alternative (if applicable) ADDITIONS TO THE PDL

ABILIFY MAINTENA 300 mg, 400 mg extended-release powder for suspension for injection

Antipsychotic/Antimani ac agent

Added to the PDL w/ PA & QL: 1 vial / 28 days

clindamycin 1 % pad Dermatological agent Added to the PDL w/ QL: 60 pads / 30 days

clobetasol propionate 0.05 % solution

Dermatological agent Added to the PDL

desonide 0.05 % ointment

flutamide 125 mg capsule

Antineoplastic Added to the PDL

hydrocortisone 0.5 % Dermatological agent Added to the PDL

UPDATE

WellCare’s New York Medicaid

Preferred Drug List

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INVEGA SUSTENNA 117 mg/0.75 ml

suspension for injection

Added to the PDL w/ PA & QL: 0.75 ml / 28 days INVEGA SUSTENNA

156 mg/ml suspension for injection

Added to the PDL w/ PA & QL: 1 ml / 28 days

INVEGA SUSTENNA 234 mg/1.5 ml

39 mg/0.25 ml

78 mg/0.5 ml

Added to the PDL w/ PA & QL: 0.5 ml / 28 days INVEGA TRINZ

273/0.875 ml

Added to the PDL w/ PA & QL:

0.875 ml / 91 days

INVEGA TRINZ 410/1.315 ml

1.315 ml / 91 days

INVEGA TRINZ 546/1.75 ml

Added to the PDL w/ PA & QL: 1.75 ml / 91 days INVEGA TRINZ

819/2.625 ml

2.625 ml / 91 days

leucovorin calcium 50 mg powder for injection

MAVYRET 100-10 mg oral tablet

Antiviral Added to the PDL w/ PA

methotrexate 25 mg/ml multi-dose vial for

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omega-3-acid ethyl esters 1 gram capsules

Antihyperlipidemic Added to the PDL

triamcinolone acetonide 0.5 % ointment

ZEGERID 20-1100 mg capsule

Ulcer drug Added to the PDL

UTILIZATION MANAGEMENT CHANGES REMOVALS FROM THE PDL diazepam 5 mg/ml

injection for solution

Antianxiety agents Removed from the PDL/LU

diazepam oral and rectal gel

EPCLUSA 400-100 mg oral tablet

Antiviral Removed from

the PDL/PC

MAVYRET 100-10 mg oral tablet naproxen sodium 275

mg, 550 mg oral tablet

Analgesics-Anti- Inflammatory

Removed from the PDL/PC

naproxen oral tablet 250 mg, 375 mg, 500 mg

SEREVENT DISKUS aerosol powder breath activated 50 mcg/dose inhalation

Antiasthmatic Removed from the PDL/LU

FORADIL aerolizer kit 12 mcg powder for inhalation

ZEPATIER 50-100 mg oral tablet

Antiviral Removed from

the PDL/PC

MAVYRET 100-10 mg oral tablet

Dear Provider:

09/21/2017

Dear Provider:

At the September 21,2017 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to WellCare’s New York Medicaid Preferred Drug List (PDL), effective 12/05/2017. Please carefully review these changes.

Key

UPPER CASE = Brand Name Drugs PA = Prior Authorization

QL = Quantity Limits PDL = Preferred Drug List ST = Step Therapy YOA = Years of Age AL = Age Limit

UPDATE

WellCare’s New York Medicaid

Preferred Drug List

If you have questions, WellCare of New York’s Health Plan’s Pharmacy Help Desk is available to assist providers at 1-800-288-5441.

Thank you for your care of WellCare’s New York Medicaid members.

Sincerely,

WellCare Health Plans, Inc.