WellCare of Nebraska

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PRO_09758E_ State Approved 01102018 NA7CADFRM09758E_0000

©WellCare 2017 09/13/2018 Dear Provider:

At the September 13,2018 WellCare of Nebraska Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare of Nebraska

Children’s Health Insurance Program

Preferred Drug List (PDL), effective 11/27/2018. 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: 11/27/2018

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

ARISTADA INITIO vial

Antipsychotic Added to the PDL w/ PA & QL:

QL: 2.4 ml / 365 days

HUMIRA PEN- CD/UC/HS STARTER 80mg/0.8ml kit

Analgesics-Anti- Inflammatory

Added to the PDL w/ PA

HUMIRA PEN- PS/UV STARTER 80mg/0.8ml & 40 mg/0.4ml kit

Analgesics-Anti- Inflammatory

Added to the PDL w/ PA

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

UPDATE