©WellCare 2016 NE_05_16

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

03/02/2017 Dear Provider:

At the March 2, 2017 <WellCare of Nebraska> Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the <WellCare of Nebraska> Preferred Drug List (PDL), effective 05/16/2017. 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: 05/16/2017

Drug Name Therapeutic Class Change PDL Alternative (if applicable)

BD pen needles Diabetic Supplies Added to the PDL w/ QL & AL: 200 pen needles / 31 days for members 21 YOA and younger & 100 pen needles / 31 days for members over 21 YOA

ESTRADIOL biweekly 0.1 mg/24 hr

transdermal patch

Hormones and hormone modifiers

Added to the PDL

FERRETS 325 mg tablet

Nutritional Supplement

Added to the PDL

UPDATE

<WellCare of Nebraska>

Preferred Drug List

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

ferrous fumarate 324 mg tablet

Nutritional Supplement

Added to the PDL

ferrous sulfate 220 mg/5ml liquid

Nutritional Supplement

Added to the PDL

FOLBEE 2.5-25-1 mg tablet

Nutritional Supplement

Added to the PDL

JOHNSON &

JOHNSON diabetic supplies-strips &

meters (OneTouch)

Diabetic Supplies Added to the PDL w/ QL & AL: 200 test strips / 31 days for members 21 YOA and younger

& 100 test strips / 31 days for members over 21 YOA

PREMPRO 0.3-1.5 mg tablet

Hormones and hormone modifiers

Added to the PDL

VITAMIN B-12 250 mcg tablet

Nutritional Supplement

Added to the PDL

REMOVALS FROM THE PDL ABBOT/ROCHE

diabetic supplies

Diabetic Supplies Removed from the PDL/ PC

JOHNSON &

JOHNSON diabetic supplies-strips &

meters (OneTouch) EXJADE 125 mg, 250

mg, 500 mg tablet

Antidote Removed from the PDL/ PC

JADENU 90 mg, 180 mg, 360 mg oral tablet

PREMARIN

reconstituted 25 mg solution for injection

Hormones and hormone modifiers

Removed from the PDL/ LU

PREMARIN oral tablet,

estradiol transdermal patch

SURE COMFORT pen needles 31 G X 8 MM

Diabetic Supplies Removed from the PDL/ PC

BD pen needles

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.

NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16

Sincerely,

<WellCare of Nebraska>