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PRO_27552E Internal Approved 01082019

©WellCare 2018 NA8CADLTR27552E_0000

12/05/2019

Dear Provider,

At the December 5th, 2019 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes would be made to the South Carolina Medicaid Preferred Drug List (PDL). They will be effective 12/05/2019. Please review these changes carefully.

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: 12/05/2019

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

DELSTRIGO (Doravirine- Lamivudine-Tenofovir) 100-

300-300 mg oral tablet

Antivirals Added to PDL

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

Thank you for your care of South Carolina Medicaid members.

Sincerely,

WellCare Health Plans, Inc.

UPDATE

South Carolina Medicaid

Preferred Drug List

Referencias

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