WellCare’s New Jersey

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NJ023800_PRO_LTR_ENG Internal Approved 02112015 63816

09/13/2018

Dear Provider:

At the September 13, 2018 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare’s New Jersey Medicaid Preferred Drug List (PDL), effective 12/02/2018. 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: 12/02/2018

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

ARISTADA INITIO vial

Antipsychotic Added to the PDL PA & QL:

QL :2.4mL /365 days

ARNUITY ELLIPTA 50mcg powder

Antiasthmatic/Bron chodilator

Added to the PDL QL:31/31 days BIKTARVY 50-200-

25mg tablet

Antivirals Added to the PDL

HEPATITIS A vaccine

Vaccines Added to the PDL w/ AL:

AL: Members 19 YOA & older:

Members 18 YOA

UPDATE

WellCare’s New Jersey

Preferred Drug List

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& younger:

Product/Service not covered for patient age;

Excluded for patient age;

Minimum patient age of 19 YOA 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

Added to the PDL w/ PA

ZENPEP 10000 unit capsules

Digestive Enzymes Added to the PDL

UTILIZATION MANAGEMENT CHANGES clindamycin

phosphate 1%

solution

Dermatological agents

QL added:

QL: 120 ml / 31 days

SPINOSAD 0.9%

suspension

ST added

REMOVALS FROM THE PDL DRYSOL 20%

solution

Removed from the PDL/PC

HYPERCARE solution 20%

external econazole 1% cream Dermatological

agents

clotrimazole 1%

cream external, ketoconazole 2%

cream external FORADIL aerolizer

capsule 12mcg for inhalation

Antiasthmatic and Bronchodilator agents

Removed from the PDL/DD

STRIVERDI

RESPIMAT aerosol solution 2.5

mcg/act inhalation, VENTOLIN HFA inhalation aerosol

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solution 108 (90 base) mcg/act lidocaine 5%

ointment

lidocaine hcl solution 4 % external lidocaine hcl external 2% gel naproxen oral

suspension 125 mg/5mL

ibuprofen oral suspension 100 mg/5mL tronvite 1mg tablet Multivitamins Removed from

the PDL/PC

DIALYVITE tablet, rena-vite tablet, triphrocaps 1mg

If you have questions, WellCare’s Pharmacy Help Desk is available to assist providers 1- 888-453-2534.

Thank you for your care of WellCare’s New Jersey members.

Sincerely,

WellCare Health Plans, Inc.