WellCare’s Georgia Preferred Drug List (PDL) Update
This is a list of changes to our preferred drug list. We made the changes as a result of the latest WellCare Pharmacy &
Therapeutics meeting on 09/21/2017.
Please look at these changes. Please call Customer Service at 1-866-231-1821 if you have any questions. The most current version of the PDL is on our website at https://georgia.wellcare.com/member/preferreddruglist. You can also have a copy mailed to you. Just call us. We are happy to help.
Date of Change: 12/05/2017
DRUG NAME DESCRIPTION OF
CHANGE REASON FOR CHANGE Requirements/Limits/Alternatives
ABILIFY MAINTENA 300 mg,400 mg extended-release powder for suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 1 vial / 28 days
CHANTINX STARTING MONTH PAK 0.5 mg X 11 & 1 mg X 42 tablet
Added to the PDL w/ QL General PDL Update QL: 53 tablets / 365 days
CHANTIX 0.5 mg, 1 mg tablet Added to the PDL w/ QL General PDL Update QL: 112 tablets / 365 days
CHANTIX CONTINUING MONTH PAK 1 mg tablet
Added to the PDL w/ QL General PDL Update QL: 112 tablets / 365 days
clindamycin 1 % pad Added to the PDL w/ QL General PDL Update QL: 60 pads / 30 days clobetasol propionate 0.05 %
solution
Added to the PDL General PDL Update
desonide 0.05 % ointment Added to the PDL General PDL Update
EPCLUSA 400-100 mg oral Removed from the PDL General PDL Update MAVYRET 100-10 mg oral tablet
tablet
flutamide 125 mg capsule Added to the PDL General PDL Update hydrocortisone 0.5 % cream Added to the PDL General PDL Update INVEGA SUSTENNA 117
mg/0.75 ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 0.75 ml / 28 days
INVEGA SUSTENNA 156 mg/ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 1 ml / 28 day
INVEGA SUSTENNA 234 mg/1.5 ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 1.5 ml / 28 days
INVEGA SUSTENNA 39 mg/0.25 ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 0.25 ml / 28 days
INVEGA SUSTENNA 78 mg/0.5 ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 0.5 ml / 28 days
INVEGA TRINZ 273/0.875 ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 0.875 ml / 91 days
INVEGA TRINZ 410/1.315 ml suspension for injection
Added to the PDL w/ PA & QL General PDL Update PA & QL: 1.315 ml / 91 days
powder for injection
MAVYRET 100-10 mg oral tablet
Added to the PDL w/ PA General PDL Update PA
methotrexate 25 mg/ml multi- dose vial for injection
Added to the PDL General PDL Update
naproxen sodium 275 mg, 550 mg oral tablet
Removed from the PDL General PDL Update naproxen oral tablet 250 mg, 375 mg, 500 mg
NICOTROL 10 mg/ml nasal spray
Added to the PDL General PDL Update
NICOTROL inhaler Added to the PDL General PDL Update omega-3-acid ethyl esters 1
gram capsules
Added to the PDL General PDL Update
SEREVENT DISKUS aerosol powder breath activated 50 mcg/dose inhalation
Removed from the PDL General PDL Update FORADIL aerolizer kit 12 mcg powder for inhalation
triamcinolone acetonide 0.5 % ointment
Added to the PDL General PDL Update
ZEGERID 20-1100 mg capsule
Added to the PDL General PDL Update
ZEPATIER 50-100 mg oral tablet
Removed from the PDL General PDL Update MAVYRET 100-10 mg oral tablet
Generic Drugs
italics BRAND
DRUGS CA
PS
PDL Preferred Drug List
P A
Prior
Authorization
Q L
Quantity Limited
ST Step Therapy
WellCare proudly serves Georgia Families®, PeachCare for Kids® and Planning for Healthy Babies® members.
If you speak a different language or need something in Braille or audio, don’t worry. We can provide translations and alternate formats at no cost to you. Just give us a call toll-free. Georgia Families® and PeachCare for Kids® members call 1-866-231-1821.
Planning for Healthy Babies® members call 1-877-379-0020. All TTY users call 1-877-247-6272.
Si habla otro idioma o si necesita información en Braille o en audio, no se preocupe. Podemos ofrecerle traducciones y formatos alternativos sin costo para usted. Simplemente llámenos sin costo. Los miembros de Georgia Families® y PeachCare for Kids® llamen al 1-866-231-1821. Los miembros de Planning for Healthy Babies® llamen al 1-877-379-0020. Todos los usuarios de TTY llamen al 1-877-247-6272.