P.O. Box 31577
Tampa, FL 33631-3577
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PRO_24180E_C Internal Approved HI8CADLTR24180E_0000
© WellCare 2018 Dear Provider:
At the March 7, 2019 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the ‘Ohana QUEST Integration Medicaid Preferred Drug List (PDL). 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 CR = Clinical Removal Effective date of change: 5/21/2019
Drug Name Therapeutic Class Change/Reason for Change
PDL Alternative (if applicable) ADDITIONS TO THE PDL
amlodipine /valsartan 5-320mg tablet
Antihypertensives Added to PDL dexamethasone
1mg/ml concentration
Corticosteroids Added to PDL
dexamethasone phosphate 10mg/ml vial
Corticosteroids Added to PDL
dexamethasone phosphate 20mg/5ml injection
Corticosteroids Added to PDL
dexamethasone phosphate 120mg/30 injection
Corticosteroids Added to PDL
OCUSOFT hypochlorous liquid
Dermatologicals Added to PDL
UPDATE
‘Ohana QUEST Integration Medicaid
Preferred Drug List
P.O. Box 31577
Tampa, FL 33631-3577
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PRO_24180E_C Internal Approved HI8CADLTR24180E_0000
© WellCare 2018
OCUSOFT lid scrub foaming solution
Dermatologicals Added to PDL OCUSOFT lid scrub
original liquid
Dermatologicals Added to PDL REMOVALS FROM THE PDL levothyroxine
500mcg vial
Thyroid Removed from
PDL/LU
levothyroxine oral tablets (all
strengths) Effective date of change: 2/13/2019
Drug Name Therapeutic Class Change/Reason for Change
PDL Alternative (if applicable) ADDITIONS TO THE PDL
FLOVENT HFA 110 mcg/act, 220
mcg/act, aerosol
Antiasthmatic And Bronchodilator Agents
AL added: max 12 YOA
QL added: grams / 30 days
FLOVENT HFA 44 mcg/act aerosol
Antiasthmatic And Bronchodilator Agents
AL updated: max 12 YOA
QL added: 10.6 grams / 30 days wixela inhub aerosol
100/50 mcg: 250/50 mcg; 500/50 mcg
Antiasthmatic And Bronchodilator Agents
QL added: 60 each/ 30 days
If you have questions, ‘Ohana Health Plan’s Pharmacy Help Desk is available to assist providers at 1-888-846-4262.
Thank you for your care of ‘Ohana Medicaid members.
Sincerely,
’Ohana Health Plan Pharmacy
‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
