WellCare’s South Carolina

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SC028307_PRO_LTR_ENG State Approved 01142015 63822

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 South Carolina Medicaid 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 PA & QL:

QL :2.4mL /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 patient age;

Minimum patient age of 19 YOA

UPDATE

WellCare’s South Carolina

Preferred Drug List

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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

Dermatological agents

ST added

SHORT ACTING OPIOIDS

Analgesics-Opioid Covered:

7 day initial fill limit for short-acting opioids

90 MME daily max edit

Opioid-

Benzodiazepine concurrent use edit REMOVALS FROM THE PDL

DRYSOL 20% solution Dermatological agents

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

agents

lidocaine hcl solution 4 % external

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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 at 1-888- 588-9842.

Thank you for your care of WellCare’s South Carolina Medicaid members.

Sincerely,

WellCare Health Plans, Inc.