Preferred Drug List

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KY028299_PRO_LTR_ENG Internal Approved 12082014 63815

Dear Provider:

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

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

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

Antipsychotic/Antima niac 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 % cream

UPDATE

WellCare of Kentucky Medicaid

Preferred Drug List

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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

Added to the PDL w/ PA & QL: 1.5 ml / 28 days

INVEGA SUSTENNA 39 mg/0.25 ml

Added to the PDL w/ PA & QL: 0.25 ml / 28 days INVEGA SUSTENNA

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

546/1.75 ml

819/2.625 ml

Added to the PDL w/ PA & QL: 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 injection

NICOTROL 10 mg/ml nasal spray

Psychotherapeutic and Neurological agents-Misc

Added to the PDL

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NICOTROL inhaler Psychotherapeutic and Neurological agents-Misc

Added to the PDL

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 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

If you have questions, WellCare of Kentucky’s Pharmacy Help Desk is available to assist providers at 1-877-389-9457.

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

Sincerely,

WellCare Health Plans, Inc.