P.O. Box 31577
Tampa, FL 33631-3577
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FL7CADLTR08370E_0000 Internal Approved 10242017
© WellCare 2017 PRO_08370E_
10/24/2018
Dear Provider:
At the October 24, 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
AMITIZA 8 mcg & 24 mcg capsule
Gastrointestinal agents-misc
Added to the PDL w/ PA
REMOVALS FROM THE PDL ASMANEX metered
dose twisthaler- all strengths
Antiasthmatic and Bronchodilator agents
Removed from the PDL (LU)
ARNUITY ELLIPTA 50 mcg/act, 100 mcg/act & 200 mcg/act powder for inhalation
QVAR REDIHALER 40 mcg/act & 80 mcg/act aerosol ASMANEX HFA 100
mcg/act inhalation aerosol
Antiasthmatic and Bronchodilator agents
Removed from the PDL(LU)
ARNUITY ELLIPTA 50 mcg/act, 100 mcg/act & 200
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_
mcg/act powder for inhalation
QVAR REDIHALER 40 mcg/act & 80 mcg/act aerosol FLOVENT DISKUS
50 mcg/act 100 mcg/act/ & 250 mcg/act powder for inhalation
Antiasthmatic and Bronchodilator agents
Removed from the PDL(LU)
ARNUITY ELLIPTA 50 mcg/act, 100 mcg/act & 200 mcg/act powder for inhalation
QVAR REDIHALER 40 mcg/act & 80 mcg/act aerosol FLOVENT HFA 44
mcg/act, 110 mcg/act
& 220 mcg/act inhalation aerosol
Antiasthmatic and Bronchodilator agents
Removed from the PDL (PC)
ARNUITY ELLIPTA 50 mcg/act, 100 mcg/act & 200 mcg/act powder for inhalation
QVAR REDIHALER 40 mcg/act & 80 mcg/act aerosol QVAR 40 mcg/act &
80 mcg/act inhalation aerosol
Antiasthmatic and Bronchodilator agents
Removed from the PDL(LU)
ARNUITY ELLIPTA 50 mcg/act, 100 mcg/act & 200 mcg/act powder for inhalation
QVAR REDIHALER 40 mcg/act & 80 mcg/act aerosol SPIRIVA RESPIMAT
1.25 mcg/act & 2.5 mcg/act inhalation solution
Antiasthmatic and Bronchodilator agents
Removed from the PDL(PC)
INCRUSE ELLIPTA 62.5 mcg/act
powder for inhalation
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
