WellCare s South Carolina Preferred Drug List Update

Transcription

1 WellCare s South Carolina Preferred Drug List Update This is a list of changes to our preferred drug list. These are a result of the latest WellCare Pharmacy & Therapeutics meeting held on 09/03/2015. Please look at these changes. Call WellCare s South Carolina Customer Service at if you have any questions. You can view an updated version of the complete preferred drug list. It is on our website at You can ask for a printed copy to be mailed to you. Just call customer service. They are happy to help. Date of Change: 11/03/2015 REASON FOR Requirements/Limits/Alternatives ABILIFY tablets - all strengths Removed from the PDL General PDL update aripiprazole tablets (ST may apply) ABSORICA 20mg, 30mg, 40mg capsules Removed from the PDL General PDL update CLARAVIS ORAL CAPSULE 10 MG, 20MG, 30 MG, 40 MG acetaminophen 500 mg capsules Removed from the PDL General PDL update acetaminophen oral tablet 500 mg ACETASOL HC otic Removed from the PDL General PDL update acetic acid 2% otic acetic acid 2% otic acetic acid/aluminum 2% otic Removed from the PDL General PDL update acetic acid 2% otic ACITRETIN 17.5 mg capsules Removed from the PDL General PDL update acne medication 5% gel Removed from the PDL General PDL update benzoyl peroxide external 10 % AFRIN 0.05% spray Removed from the PDL General PDL update pseudoephedrine hcl oral tablet 30 mg, 60 mg all day allergy 5 mg/5 ml Removed from the PDL cetirizine hcl oral syrup 1 mg/ml, 5 General PDL update mg/5ml ALTARYL 12.5 mg/5 ml syrup Removed from the PDL General PDL update diphenydramine 12.5 mg/5 ML elixir (OTC) aripiprazole tablets - all strengths ST (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.)

2 artificial tears 1.4% ophthalmic Added QL Safety Concerns QL: 15 ml/31 days bacitracin 500U/GM ointment bacitracin ophthalmic ointment bacitracin/neomycin/polymixin ointment Added to the PDL REASON FOR General PDL update Requirements/Limits/Alternatives BARACLUDE 1 mg tablets Removed from the PDL General PDL update entecavir oral tablet 0.5 mg, 1 mg benzoyl peroixde 6% lotion Removed from the PDL General PDL update benzoyl peroxide external 10 % benzoyl peroxide 2.5% liquid Removed from the PDL General PDL update benzoyl peroxide external 10 % benzoyl peroxide 5%, 10% liquid wash BP 10-1 emulsion Removed from the PDL General PDL update benzoyl peroxide external 10 % BP CLEANSING 4% lotion Removed from the PDL General PDL update benzoyl peroxide external 10 % Brom/PSE/Dm syrup bupropion hydrochloride (smoking deterrent) 150 mg SR 12HR tablets calcitriol 3 mcg/gm ointment Removed from the PDL General PDL update Please reference PDL calcium carbonate 750 mg chewables carbamoxide 6.5% otic drops child complete chewable allergy Removed from the PDL General PDL update diphenydramine 12.5 mg/5 ML elixir (OTC) children's silfedrine 15 mg/5 ml liquid clemastine 0.5 mg/5 ml syrup Removed from the PDL General PDL update diphenydramine 12.5 mg/5 ML elixir (OTC) clotrimazole-betamethasone % cream DELSYM 5-5 mg cough lozenges Removed from the PDL General PDL update Please reference PDL dexmethylphenidate 20 mg SR QL 31/31 days:

3 24 HR capsules AL: Min 6 YOA, Max 20 YOA dextroamphetamine extendedrelease capsules - all strengths Removed ST Safety Concerns QL 31/31 days: AL: Min 6 YOA, Max 20 YOA diphenydramine 12.5 mg/5 ML elixir (OTC) diphenydramine 50 mg/ml injection REASON FOR Requirements/Limits/Alternatives duloxetine 20mg, 60mg capsules Removed ST Safety Concerns QL: 62 caps/31 days duloxetine 30mg capsules Removed ST Safety Concerns QL: 31 caps/31 days EURAX 10% cream, lotion Removed from the PDL General PDL update permethrin external cream 5 % eye lubricant ophthalmic ointment first-lansoprazole suspension ST: T/F of omeprazole capsules and ranitidine syrup GARDASIL injection AL: Min 19 YOA, Max 26 YOA HUMALOG KWIK 200U/mL QL: 30 ml/30 days injection hydrocortisone/aloe 1% cream INSULIN PEN MIS 31GX4MM QL: 100/31 days invisible acne 10% cream Removed from the PDL General PDL update benzoyl peroxide external 10 % ketoralac 0.5% ophthalmic KLOR-CON 20meq, 25meq packets Removed from the PDL General PDL update potassium chloride oral 20 meq/15ml (10%) lice treatment 1% liquid Removed from the PDL General PDL update lice killing % shampoo LOTEMAX 0.5% ophthalmic gel MESTINON timespan tablets Removed from the PDL General PDL update pyridostigmine 180 mg tablets metaproterenol 10 mg/5 ml syrup methylphenidate 10 mg extended-release tablets metipranolol 0.3% ophthalmic Removed from the PDL General PDL update albuterol sulfate oral syrup QL: 93/31 days AL: Min 6 YOA, Max 20 YOA Removed from the PDL General PDL update levobunolol hcl ophthalmic ; timolol maleate ophthalmic

4 metronidazole 0.75% gel MUCINEX 1200 mg tablets MUCINEX-D mg tablets mucus relief 600 mg extendedrelease tablets REASON FOR Requirements/Limits/Alternatives MYORISAN 10mg, 20mg, 40mg capsules Removed from the PDL General PDL update CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG NAMENDA XR, titration pack XR Removed from the PDL General PDL update memantine oral tablets 5mg,10mg - all strengths naproxen 500 mg delayedrelease tablets Removed from the PDL General PDL update naproxen sodium oral tablet 275 mg, 550 mg nasal decongestant 10 mg tablets Removed from the PDL General PDL update pseudoephedrine hcl oral tablet 30 mg, 60 mg NOVOLOG MIX 70/30 QL: 60 ml/31 days suspension, NOVOLOG MIX 70/30 FLEXPEN, NOVOLOG PENFILL 100 u/ml, NOVOLOG FLEXPEN, 100 u/ml, NOVOLIN N 100 u/ml, NOVOLIN N RELION 100 u/ml, NOVOLIN 70/30 suspension, NOVOLIN 70/30 RELION suspension, NOVOLIN R 100 u/ml, NOVOLIN R RELION 100 u/ml PNEUMOVAX mg/0.5 ml AL: Min 19 YOA injection PREVNAR-13 injection AL: Min 19 YOA promethazine VC 6.25mg/5mg/5 ml syrup promethazine 12.5 mg, 50 mg Removed from the PDL General PDL update Promethazine 25mg suppositories suppositories promethazine 25 mg/ml, 50 Removed from the PDL General PDL update Promethazine 25mg suppositories

5 mg/ml injection pseudoephedrine 120 mg extended-release tablets pyrethins-piperonyl butoxide Removed from the PDL General PDL update lice killing % shampoo external liquid % REASON FOR Requirements/Limits/Alternatives pyridostigmine 180 mg tablets RID liquid Removed from the PDL General PDL update lice killing % shampoo saline 0.65% nasal spray salivasure lozenges Removed from the PDL General PDL update pilocarpine hcl oral tablet 5 mg, 7.5 mg SANTYL 250U/G ointment PA SAPHRIS 2.5 mg sublingual ST: Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days. AL: Min 18 YOA SSD 1% cream QL: 400/31 days sodium chloride 3%, 7% nebulizer sodium fluoride 0.2% mint Removed from the PDL General PDL update sodium fluoride oral 1.1 (0.5 f) mg/ml sodium fluoride 0.2% Removed from the PDL General PDL update sodium fluoride oral 1.1 (0.5 f) mg/ml sodium sulfacetamide-sulfur 10-5% cream, lotion Removed from the PDL General PDL update sulfacetamide sodium external suspension 10 % TASMAR 100 mg tablets Removed from the PDL General PDL update tobramycin/dexamethasone % ophthalmic suspension tolnaftate 1% Removed from the PDL General PDL update Please reference PDL trazodone 300 mg tablets Removed from the PDL General PDL update trazodone hcl oral tablet 100 mg, 150 mg, 50 mg ZOSTAVAX injection Added to the PDL Safety Concerns AL: Min 50 YOA

6 Generic Drugs italics BRAND DRUGS CA PS PDL Preferred Drug List P A Prior Authorization Q L Quantity Limit ST Step Therapy A L Age Limit YO A Years of Age