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P.O. Box 31577

Tampa, FL 33631-3577

Page 1 of 2

FL7CADLTR08370E_0000 Internal Approved 10242017

© WellCare 2017 PRO_08370E_

10/15/2018

Dear Provider:

At the October 15, 2018 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the Staywell Kids Preferred Drug List (PDL), effective 01/01/2019. 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: 01/01/2019

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

buprenorphine hcl- naloxone hcl 8-2 mg sublingual tablet

buprenorphine hcl- naloxone hcl 2-0.5 mg sublingual tablet

Analgesics-Opioid Added to the PDL w/ PA

REMOVALS FROM THE PDL All strengths of

ZUBSOLV sublingual tablet

Analgesics-Opioid Removed from the PDL(PC)

buprenorphine hcl- naloxone hcl 8-2

UPDATE

Staywell Kids Medicaid

Preferred Drug List

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P.O. Box 31577

Tampa, FL 33631-3577

Page 2 of 2

FL7CADLTR08370E_0000 Internal Approved 10242017

© WellCare 2017 PRO_08370E_

mg sublingual tablet

buprenorphine hcl- naloxone hcl 2-0.5 mg sublingual tablet

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

Referencias

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