WellCare’s New York Medicaid

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NY028302_PRO_LTR_ENG Internal Approved 12152014 63821

Dear Provider:

At the September 13, 2018 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to WellCare’s New York Medicaid Preferred Drug List (PDL), effective 11/27/2018. Please carefully review these changes.

Key

UPPER CASE = Brand Name Drugs PA = Prior Authorization Lower case italics = Generic Drugs QL = Quantity Limits PDL = Preferred Drug List ST = Step Therapy YOA = Years of Age AL = Age Limit 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/Reason for 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

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 & younger:

Product/Service not covered for patient age;

Excluded for

UPDATE

WellCare’s New York Medicaid

Preferred Drug List

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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 aripiprazole 2mg,

5mg, 10mg, 15mg, 20mg tablet

Antipsychotics/Antim anic agents

ST removed

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 of New York’s Health Plan’s Pharmacy Help Desk is available to assist providers at 1-800-288-5441.

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

Sincerely,

WellCare Health Plans, Inc.