of Nebraska

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PRO_09757_ State Approved 12112017 NE7CADFRM09757_0000

©WellCare 2017 NE_12_17 06/07/2018

Dear Provider:

At the June 7, 2018 WellCare of Nebraska Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare

of Nebraska

Supplemental Drug List (DL), effective 08/21/2018. Please carefully review these changes:

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: 08/21/2018

Drug Name Therapeutic Class Change PDL Alternative (if applicable) ADDITIONS TO THE PDL

lactulose

encephalopathy 10gm/15ml solution

Laxatives Added to the PDL

UTILIZATION MANAGEMENT CHANGES ARISTADA

882mg/3.2 ml pre- filled syringe

Antipsychotics/Anti manic agents

QL updated:

QL: 3.2 ml / 28 days

REMOVALS FROM THE PDL lidocaine 5%

ointment

Dermatologicals Removed from the PDL/PC

lidocaine 2% gel external,

lidocaine-prilocaine cream

UPDATE

WellCare of Nebraska

Supplemental Drug List

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PRO_09757_ State Approved 12112017 NE7CADFRM09757_0000

If you have questions, our Pharmacy Help Desk is available to help you at 1-855-599- 3814.

Thank you for providing excellent care to WellCare of Nebraska members.

Sincerely,