©WellCare 2016 NE_05_16

(1)

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

NA6PROLTR76215E_0516

09/21/2017 Dear Provider:

At the September 21,2017 <WellCare of Nebraska> Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare of Nebraska Family Planning Preferred Drug List (PDL), effective 12/05/2017. 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: 12/05/2017

Drug Name Therapeutic Class Change PDL Alternative (if applicable)

ADDITIONS TO THE PDL

ABILIFY MAINTENA 300 mg, 400 mg extended-release powder for suspension for injection

Antipyschotic/Antima niac agent

Added to the PDL w/ PA & QL: 1 vial / 28 days

butalbital-apap-caff- codeine 50-325-40-30 mg oral capsule

Analgesics-Opioid Added to the PDL w/ QL: 150

capsules / 30 days

doxepin hcl 150 mg oral capsule

Antidepressant Added to the PDL

INVEGA SUSTENNA 117 mg/0.75 ml

suspension for injection

Antipsychotic/Antima niac agent

Added to the PDL w/ PA & QL: 0.75 ml / 28 days INVEGA SUSTENNA Antipsychotic/Antima Added to the PDL

UPDATE

<WellCare of Nebraska Family Planning>

Preferred Drug List

(2)

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

156 mg/ml suspension for injection

niac agent w/ PA & QL: 1 ml / 28 days

Added to the PDL w/ PA & QL: 1.5 ml / 28 days

INVEGA TRINZ 273/0.875 ml

irbesartan 75 mg, 150 mg, 300 mg tablet

Antihypertensive Added to the PDL

rizatriptan benzoate dispersible 5 mg, 10 mg oral tablet

Migraine Product Added to the PDL

ZEGERID 20-1100 mg capsule

Ulcer drug Added to the PDL

UTILIZATION MANAGEMENT CHANGES diclofenac sodium 1 %

gel

Dermatological agent QL update: QL: 200 GM / 31 days

REMOVALS FROM THE PDL diazepam 5 mg/ml

injection for solution

Antianxiety agent Removed from the PDL/LU

diazepam oral and rectal gel

(3)

NA034159_PRO_LTR_ENG State Approved 12132016 76215

SEREVENT DISKUS aerosol powder breath activated 50 mcg/dose inhalation

Antiasthmatic Removed from the PDL/LU

FORADIL aerolizer kit 12 mcg powder for inhalation

©WellCare 2016 NE_05_16

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

09/21/2017 Dear Provider:

At the September 21,2017 <WellCare of Nebraska> Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare of Nebraska Family Planning Preferred Drug List (PDL), effective 12/05/2017. Please carefully review these changes:

Key

UPPER CASE = Brand Name Drugs QL = Quantity Limit

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: 12/05/2017

Drug Name Therapeutic Class Change PDL Alternative (if applicable)

UPDATE

<WellCare of Nebraska Family Planning>

Preferred Drug List

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

If you have questions, our Pharmacy Help Desk is available to help you at 1-855-599- 3814.

Thank you for providing excellent care to <WellCare of Nebraska> members.

Sincerely,

<WellCare of Nebraska>