Preferred Drug List

(1)

Page 1 of 3

IL028298_PRO_LTR_ENG Internal Approved 12082014 63811

©WellCare 2014 IL_10_15 09/13/2018

Dear Provider:

At the September 13, 2018 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the Harmony Medicaid Preferred Drug List (PDL), effective 11/27/2018. 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: 11/27/2018

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

ARISTADA INITIO vial

Added to the PDL w/ PA & QL

General PDL Update

PA & QL:

QL: 2.4 ml / 365 days BIKTARVY 50-200-

25mg tablet

Antivirals Added to the PDL

HEPATITIS A vaccine

Vaccines Added to the PDL w/ AL:

AL: Members 19 YOA & older:

Members 18 YOA

& younger:

Product/Service not covered for patient age;

Excluded for patient age;

UPDATE Harmony

Preferred Drug List

(2)

Page 2 of 3

©WellCare 2014 IL_10_15

Minimum patient age of 19 YOA HUMIRA PEN-

CD/UC/HS STARTER 80mg/0.8ml kit

Analgesics-Anti- Inflammatory

Added to the PDL w/ PA

HUMIRA PEN- PS/UV STARTER 80mg/0.8ml & 40 mg/0.4ml kit

Added to the PDL w/ PA

ZENPEP 10000 unit capsules

Digestive Enzymes Added to the PDL

UTILIZATION MANAGEMENT CHANGES clindamycin

phosphate 1%

solution

Dermatological agents

QL added:

QL: 120 ml / 31 days

SPINOSAD 0.9%

suspension

ST added

REMOVALS FROM THE PDL DRYSOL 20%

solution

Removed from the PDL/PC

HYPERCARE solution 20%

external econazole 1% cream Dermatological

agents

clotrimazole 1%

cream external, ketoconazole 2%

cream external FORADIL aerolizer

capsule 12mcg for inhalation

Antiasthmatic and Bronchodilator agents

Removed from the PDL/DD

STRIVERDI

RESPIMAT aerosol solution 2.5

mcg/act inhalation, VENTOLIN HFA inhalation aerosol solution 108 (90 base) mcg/act lidocaine 5%

ointment

lidocaine hcl solution 4 %

(3)

Page 3 of 3

external lidocaine hcl external 2% gel naproxen oral

suspension 125 mg/5mL

ibuprofen oral suspension 100 mg/5mL tronvite 1mg tablet Multivitamins Removed from

the PDL/PC

DIALYVITE tablet, rena-vite tablet, triphrocaps 1mg

If you have questions, Harmony Health Plan’s Pharmacy Help Desk is available to assist providers at 1-800-608-8158.

Thank you for your care of Harmony Medicaid members.

Sincerely,

Harmony Health Plan