WellCare’s South Carolina

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09/21/2017

Dear Provider:

At the September 21, 2017 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 12/05/2017. 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: 12/05/2017

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

ABILIFY MAINTENA 300 mg, 400 mg extended-release powder for suspension for injection

Antipsychotic/Antima niac agent

Added to the PDL w/ PA & QL: 1 vial / 28 days

BEXSERO suspension for injection

Vaccines Added to the PDL w/ AL & QL Members 18 YOA

& Younger:

Plan limitations exceeded;

Minimum patient age 19 years Members 19 to 25 YOA:

Covered: QL: 1 ml (2 doses) / per lifetime

UPDATE

WellCare’s South Carolina

Preferred Drug List

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Members 26 YOA

& Older:

Maximum patient age of 25 years CHANTINX STARTING

MONTH PAK 0.5 mg X 11 & 1 mg X 42 tablet

Psychotherapeutic and Neurological agents-Misc

Added to the PDL w/ QL: 53 tablets / 365 days

CHANTIX 0.5 mg, 1 mg tablet

CHANTIX

CONTINUING MONTH PAK 1 mg tablet

clindamycin 1 % pad Dermatological agent Added to the PDL w/ QL: 60 pads / 30 days

clobetasol propionate 0.05 % solution

Dermatological agent Added to the PDL

desonide 0.05 % ointment

flutamide 125 mg capsule

Antineoplastic Added to the PDL

hydrocortisone 0.5 % cream

INVEGA SUSTENNA 117 mg/0.75 ml

suspension for injection

Added to the PDL w/ PA & QL: 0.75 ml / 28 days INVEGA SUSTENNA

156 mg/ml suspension for injection

Added to the PDL w/ PA & QL: 1 ml / 28 days

Added to the PDL w/ PA & QL: 1.5 ml / 28 days

Added to the PDL w/ PA & QL: 0.25

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suspension for injection ml / 28 days INVEGA SUSTENNA

78 mg/0.5 ml

Added to the PDL w/ PA & QL: 0.5 ml / 28 days

INVEGA TRINZ 273/0.875 ml

Added to the PDL w/ PA & QL: 0.875 ml / 91 days INVEGA TRINZ

410/1.315 ml

546/1.75 ml

819/2.625 ml

Added to the PDL w/ PA & QL: 2.625 ml / 91 days leucovorin calcium 50

mg powder for injection

methotrexate 25 mg/ml multi-dose vial for injection

M-M-R II vaccine Vaccines Added to the PDL w/ AL & QL Members 19 YOA

& Older:

Covered; QL: 2 vials (2 doses) / 365 days

Members 18 YOA

& Younger:

Minimum patient age of 19 years NICOTROL 10 mg/ml

nasal spray

Added to the PDL

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NICOTROL inhaler Psychotherapeutic and Neurological agents-Misc

Added to the PDL

omega-3-acid ethyl esters 1 gram capsules

Antihyperlipidemic Added to the PDL

triamcinolone acetonide 0.5 % ointment

TRUMENBA injection Vaccines Added to the PDL w/ AL & QL:

Members 18 YOA

and younger:

Not covered;

Minimum patient age of 19 years Members 19 to 25 YOA

Covered; QL: 1.5 ml (3 doses)/ per lifetime

Members 26 YOA and older:

Not covered:

Maximum patient age of 25 YOA VARIVAX injection Vaccines Added to the PDL

w/ AL & QL:

Members 18 YOA

and younger:

Not covered;

Minimum patient age of 19 years Members 19 YOA and older:

Covered; QL: 2 vials (2 doses) / 365 days ZEGERID 20-1100 mg

capsule

Ulcer drug Added to the PDL

UTILIZATION MANAGEMENT CHANGES

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ZUBSOLV sublingual 0.7mg-0.18 mg tablet

Analgesics-Opioid Removed PA;

Added AL & QL:

Members 15 YOA

& Younger:

Minimum patient age of 16 years Members 16 YOA

& older:

Covered; QL : 62 tablets / 31 days ZUBSOLV sublingual

1.4mg-0.36 mg tablet

Added AL & QL:

Members 15 YOA

& Younger:

& older:

Added AL & QL:

Members 15 YOA

& Younger:

Not covered Members 16 YOA

& older:

Added AL & QL:

Members 15 YOA

& Younger:

& older:

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5.7mg-1.4 mg tablet

Added AL & QL:

Members 15 YOA

& Younger:

& older:

8.6mg-2.1 mg tablet

Added AL & QL:

Members 15 YOA

& Younger:

& older:

Covered; QL : 62 tablets / 31 days REMOVALS FROM THE PDL diazepam 5 mg/ml

injection for solution

Antianxiety agent Removed from the PDL/LU

diazepam oral and rectal gel

naproxen sodium 275 mg, 550 mg oral tablet

Analgesics-Anti- Inflammatory

Removed from the PDL/PC

naproxen oral tablet 250 mg, 375 mg, 500 mg

SEREVENT DISKUS aerosol powder breath activated 50 mcg/dose inhalation

Antiasthmatic Removed from the PDL/LU

FORADIL aerolizer kit 12 mcg powder for inhalation

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.

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Sincerely,

WellCare Health Plans, Inc.