WellCare of Nebraska Family

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NA034159_PRO_LTR_ENG State Approved 12132016 76215

©WellCare 2016 NE_05_16 NA6PROLTR76215E_0516

12/14/2017 Dear Provider:

At the December 14,2017 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 (DL), effective 02/27/2018. 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: 02/27/2018

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

ARNUITY ELLIPTA 200mcg, 100 mcg/act powder for inhalation

Antiasthmatic and Bronchodilator agents

Added to the PDL w/ QL: 30 blisters / 31 days

ANORO 62.5-25 mcg/act powder for inhalation

Added to the PDL w/ QL: 60 blisters / 31 days

AVONEX 30 mcg powder for injection kit

Psychotherapeutic and Neurological agents-Misc

Added to the PDL w/ PA

AVONEX 30 mcg/0.5 ml auto-injector kit pen

UPDATE

WellCare of Nebraska Family

Planning Drug List

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AVONEX 30 mcg/0.5 ml prefilled syringe kit

naloxone 0.4 mg/ml single-dose vial for injection & syringe

Antidotes Added to the PDL

NARCAN 2 mg spray Antidotes Added to the PDL NARCAN 4 mg/ 0.1

ml spray

Antidotes Added to the PDL PRESERVISION

AREDS 2 capsule

Multivitamins Added to the PDL QVAR 40 mcg, 80

mcg/act inhalation aerosol

Added to the PDL w/ QL: 8.7 grams / 31 days

STRIVERDI RESPIMAT 2.5 mcg/act inhalation solution

Added to the PDL w/ QL: 4 grams / 31 days

VITAMIN C 250, 500 mg chewable tablet

Vitamins Added to the PDL XARELTO 15 mg

tablet

Anticoagulants Added to the PDL w/ QL: 62 tablets / 31 days

XARELTO

STARTER PACK 15

& 20 mg tablet

Anticoagulants Added to the PDL w/ QL: 51 tablets / 30 days

XARELTO 20 mg tablet

Anticoagulants Added to the PDL w/ QL: 31 tablets / 31 days & ST:

Must fail

prerequisite drug (Warfarin) within the past 90 days

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UTILIZATION MANAGEMENT CHANGES naloxone 1 mg/ml

single-dose vial for injection

Antidotes Removed QL

XARELTO 10 mg tablet

Anticoagulants Removed QL REMOVALS FROM THE PDL

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