P.O. Box 31577
Tampa, FL 33631-3577
Page 1 of 2
PRO_24160E_Internal Approved 11082018
© WellCare 2018 FL8WHKLTR24160E_0000
<First Name> <Last Name>
<Address Line 1>
<Address Line 2>
<City>, <State> <ZIP>
6/13/2019 Dear Provider:
At the June 13, 2019 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the Staywell Kids Preferred Drug List (PDL), effective 08/27/2019. 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: 08/27/2019
Drug Name Therapeutic Class Change PDL Alternative (if applicable) ADDITIONS TO THE PDL
acidophilus/pectin Antidiarrheals Added to the PDL UTILIZATION MANAGEMENT CHANGES fluocinolone
acetonide 0.01 % solution
Dermatologicals QL Updated:
QL: 120 ml / 30 Days
fluocinonide 0.05 % cream
Dermatologicals QL Updated:
QL: 120 gm/ 30 days
UPDATE
Staywell Kids Medicaid
Preferred Drug List
P.O. Box 31577
Tampa, FL 33631-3577
Page 2 of 2
PRO_24160E_Internal Approved 11082018
© WellCare 2018 FL8WHKLTR24160E_0000
The changes below are general updates. They will go into effect on 07/19/2019:
REMOVALS FROM THE PDL DULERA 100/5 MCG
and 200/5MCG
Antiasthmatics Removed from the PDL/PC
WIXELA 100- 50MCG, 250-50 MCG, and
500/50MCG (QL:
60 each /30days);
ANORO ELLIPTA 62.5-25MCG (QL:
60 each /31 days);
COMBIVENT RESPIMAT 20- 100MCG (QL: 4gm /20 days)
SYMBICORT 80- 4.5MCG and 160- 4.5MCG
Antiasthmatics Removed for ages 13 and older from the PDL/PC
WIXELA 100- 50MCG, 250-50 MCG, and
500/50MCG (QL:
60 each /30days);
ANORO ELLIPTA 62.5-25MCG (QL:
60 each /31 days);
COMBIVENT RESPIMAT 20- 100MCG (QL: 4gm /20 days)
If you have questions, our Pharmacy Help Desk is available to help you at 1-866-698-5437.
Thank you for providing excellent care to Staywell Kids Medicaid members.
Sincerely, Staywell Kids
