WellCare s South Carolina Preferred Drug List Update
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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 09/21/2017. 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: 12/05/2017 DRUG NAME DESCRIPTION OF CHANGE REASON FOR CHANGE Requirements/Limits/Alternatives ABILIFY MAINTENA 300 mg, 400 mg extended-release powder for suspension for w/ PA & QL PA & QL: 1 vial / 28 days BEXSERO suspension for w/ AL & QL: AL & QL: Members 18 YOA & Younger: patient age 19 years Members 19 to 25 YOA: Covered: QL: 1 ml (2 doses) / per lifetime Members 26 YOA & Older: Plan limitations exceeded; Maximum patient age of 25 years CHANTIX STARTING MONTH PAK 0.5 mg X 11 & 1 mg X 42 tablet w/ QL QL: 53 tablets / 365 days
2 CHANTIX 0.5 mg, 1 mg tablet w/ QL QL: 112 tablets / 365 days CHANTIX CONTINUING MONTH PAK 1 mg tablet w/ QL QL: 112 tablets / 365 days clindamycin 1 % pad w/ QL QL: 60 pads / 30 days clobetasol propionate 0.05 % solution desonide 0.05 % ointment diazepam 5 mg/ml for solution Removed from the PDL diazepam oral and rectal gel flutamide 125 mg capsule hydrocortisone 0.5 % cream INVEGA SUSTENNA 117 mg/0.75 ml suspension for INVEGA SUSTENNA 156 mg/ml suspension for INVEGA SUSTENNA 234 mg/1.5 ml suspension for INVEGA SUSTENNA 39 mg/0.25 ml suspension for w/ PA & QL PA & QL: 0.75 ml / 28 day w/ PA & QL PA & QL: 1 ml / 28 days w/ PA & QL PA & QL: 1.5 ml / 28 days w/ PA & QL PA & QL: 0.25 ml / 28 days INVEGA SUSTENNA 78 w/ PA & QL PA & QL: 0.5 ml / 28 days mg/0.5 ml suspension for
3 INVEGA TRINZ 273/0.875 ml suspension for INVEGA TRINZ 410/1.315 ml suspension for INVEGA TRINZ 546/1.75 ml suspension for INVEGA TRINZ 819/2.625 ml suspension for w/ PA & QL PA & QL: ml / 91 day w/ PA & QL PA & QL: ml / 91 days w/ PA & QL PA & QL: 1.75 ml / 91 day w/ PA & QL PA & QL: ml / 91 days leucovorin calcium 50 mg powder for methotrexate 25 mg/ml multidose vial for M-M-R II vaccine w/ AL & QL AL & QL: Members 19 YOA & Older: Covered; QL: 2 vials (2 doses) / 365 days Members 18 YOA & Younger: patient age of 19 years naproxen sodium 275 mg, 550 mg oral tablet Removed from the PDL naproxen oral tablet 250 mg, 375 mg, 500 mg NICOTROL 10 mg/ml nasal spray NICOTROL inhaler omega-3-acid ethyl esters 1
4 gram capsules SEREVENT DISKUS aerosol powder breath activated 50 mcg/dose inhalation Removed from the PDL FORADIL aerolizer kit 12 mcg powder for inhalation triamcinolone acetonide 0.5 % ointment TRUMENBA w/ AL & QL AL & QL: Members 18 YOA & 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 & older: Not covered: Maximum patient age of 25 years VARIVAX w/ AL & QL 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 mg capsule ZUBSOLV sublingual 0.7mg mg tablet Removed PA; Added AL & QL: Safety Concerns AL & QL:
5 ZUBSOLV sublingual 1.4mg mg tablet ZUBSOLV sublingual 11.4mg- 2.9 mg tablet Not covered Covered; QL : 31 tablets / 31 days ZUBSOLV sublingual 2.9mg mg tablet
6 ZUBSOLV sublingual 5.7mg- 1.4 mg tablet ZUBSOLV sublingual 8.6mg- 2.1 mg tablet 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
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