P.O. Box 31577
Tampa, FL 33631-3577
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FL7CADLTR08370E_0000 Internal Approved 10242017
© WellCare 2017 PRO_08370E_
Dear Provider:
At the March 07, 2019 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the Staywell Kids Preferred Drug List (PDL). 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 CR = Clinical Removal
Effective date of change: 05/21/2019
Drug Name Therapeutic Class Change PDL Alternative (if applicable) ADDITIONS TO THE PDL
amlodipine/valsartan 5-320mg tablet
Antihypertensives Added to PDL dexamethasone
1mg/ml concentration
Corticosteroids Added to PDL
dexamethasone phosphate 10mg/ml vial
Corticosteroids Added to PDL
dexamethasone phosphate 20mg/5ml injection
Corticosteroids Added to PDL
dexamethasone phosphate
120mg/30ml injection
Corticosteroids Added to PDL
UPDATE
Staywell Kids Medicaid
Preferred Drug List
P.O. Box 31577
Tampa, FL 33631-3577
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FL7CADLTR08370E_0000 Internal Approved 10242017
© WellCare 2017 PRO_08370E_
OCUSOFT
hypochlorous liquid
Dermatologicals Added to PDL
OCUSOFT lid scrub foaming solution
Dermatologicals Added to PDL OCUSOFT lid scrub
original liquid
Dermatologicals Added to PDL REMOVALS FROM THE PDL levothyroxine
500mcg vial
Thyroid Removed from
the PDL/LU
levothyroxine tablets (all strengths) Effective date of change: 2/13/2019
Drug Name Therapeutic Class Change PDL Alternative (if applicable) ADDITIONS TO THE PDL
FLOVENT HFA 110 mcg/act, 220
mcg/act, aerosol
Antiasthmatic And Bronchodilator Agents
AL added:
max 12 YOA QL added:
12 grams / 30 days
FLOVENT HFA 44 mcg/act aerosol
Antiasthmatic And Bronchodilator Agents
AL updated:
max 12 YOA QL added:
10.6 grams / 30 days
wixela inhub aerosol 100/50 mcg: 250/50 mcg; 500/50 mcg
Antiasthmatic And Bronchodilator Agents
QL added:
60 each/ 30 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
