Preferred Drug List

(1)

P.O. Box 31577

Tampa, FL 33631-3577

Page 1 of 3

PRO_24180E_C Internal Approved HI8CADLTR24180E_0000

Dear Provider:

At the September 13, 2018 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), 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/Reason for Change

PDL Alternative (if applicable) ADDITIONS TO THE PDL

ARISTADA INITIO vial

Antipsychotic Added to the PDL w/ AL:

Members 18 YOA

& older:

Covered;

Members 17 YOA

& younger:

Plan limitations exceeded;

Minimum patient age of 18 years

BIKTARVY 50-200- 25mg tablet

Antivirals Added to the PDL

ZENPEP 10000 unit capsules

Digestive Enzymes Added to the PDL

UTILIZATION MANAGEMENT CHANGES

UPDATE

‘Ohana QUEST Integration Medicaid

Preferred Drug List

(2)

P.O. Box 31577

Tampa, FL 33631-3577

Page 2 of 3

solution

Dermatological agents

QL added:

QL: 120 mL / 31 days

GILOTRIF 20mg, 30mg, & 40mg tablet

Antineoplastic agents

QL added:

QL: 31 tablets / 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 % external lidocaine hcl external 2% gel naproxen oral

suspension 125 mg/5mL

Analgesics-Anti- Inflammatory

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, ‘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

(3)

P.O. Box 31577

Tampa, FL 33631-3577

Page 3 of 3

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.