NJ023800_PRO_LTR_ENG Internal Approved 02112015 63816
© WellCare 2014 NJ_10_15
12/14/2017 Dear Provider:
At the December 14, 2017 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 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
Antiasthmatic and Bronchodilator agents
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
Psychotherapeutic and Neurological agents-Misc
Added to the PDL w/ PA
UPDATE
WellCare’s New Jersey
Preferred Drug List
AVONEX 30 mcg/0.5 ml prefilled syringe kit
Psychotherapeutic and Neurological agents-Misc
Added to the PDL w/ PA
CEFAZOLIN 1 gram vial
Cephalosporins Added to the PDL CERTAVITE
ANTIOXIDANT tablet
Multivitamins Added to the PDL
JULUCA 50mg-25mg tablet
Antivirals Added to the PDL w/ PA
NARCAN 2 mg spray Antidotes Added to the PDL NARCAN 4 mg/ 0.1
ml spray
Antidotes Added to the PDL
QVAR 40 mcg, 80 mcg/act inhalation aerosol
Antiasthmatic and Bronchodilator agents
Added to the PDL w/ QL: 8.7 grams / 31 days
STRIVERDI RESPIMAT 2.5 mcg/act inhalation solution
Antiasthmatic and Bronchodilator agents
Added to the PDL w/ QL: 4 grams / 31 days
TAB-A-VITE/ IRON tablet
Multivitamins Added to the PDL VITAMIN C 250, 500
mg chewable tablet
Vitamins Added to the PDL VITAMIN D3 1000
unit capsule
Vitamins Added to the PDL VITAMIN D3 2000,
5000 unit tablet
Vitamins Added to the PDL VITAMIN D3 400 unit
drop
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 UTILIZATION MANAGEMENT CHANGES MEPHYTON 5mg
tablet
Vitamins QL added:
QL: 31 tablets / 31 days
naloxone 0.4mg/ml, 1 mg/ml single-dose vial for injection
Antidotes Removed QL
naloxone 0.4 mg/ml single-dose vial for injection & syringe
Antidotes Removed QL
XARELTO 10 mg tablet
Anticoagulants Removed QL REMOVALS FROM THE PDL lidocaine-prilocaine
2.5-2.5 % kit
Dermatologicals Removal from the PDL/PC
lidocaine external ointment 5
% or lidocaine hcl external gel 2 %
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.
