UPDATE Ohana QUEST Integration Medicaid

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1 UPDATE Ohana QUEST Integration Medicaid Preferred Drug List March 26, 2015 Dear Provider: At the March 05, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the Ohana QUEST Integration Medicaid Preferred Drug List (PDL), effective May 15, Please carefully review these changes. UPPER CASE = Brand Name Drugs Lower case italics = Generic Drugs PDL = Preferred Drug List PA = Prior Authorization SC = Safety Concerns PC = Pharmacoeconomic Considerations GA = Generic Available Effective date of change: May 15, 2015 Key QL = Quantity Limit ST = Step Therapy AL = Age Limit YOA = Years of Age LU = Low Utilization DD = Discontinued Drug Drug Name Therapeutic Class Change acyclovir 5% ointment BENICAR - all ADDITIONS TO THE PDL Dermatologicals; Antivirals - Topical Antihypertensives;A ngiotensin II Receptor Antagonists preferred oral acyclovir or valacyclovir within the past 100 days). losartan and valsartan). PDL Alternative (if colchicine 0.6 mg Gout Agents desogestrel/ethinyl estradiol doxycycline monohydrate 50 mg, 100 mg Tetracyclines Page 1 of 5 drospirenone/ethinyl

2 estradiol 3.0 mg-0.03 mg DROXIA - all duloxetine - all ferrous fumarate 325 mg ferrous sulfate 220 mg/5 ml liquid guanfacine hydrochloride 24 hr sustained-release - all HARVONI 90 mg mg insupen mis 33Gx4mm lamivudine 10 mg/ml levonorgestrel/ethinyl estradiol 0.1 mg-0.02 mg methylprednisolone 4 mg mycophenolate mofetil 200 mg/ml oral suspension Agents; Agents For Sickle Cell Anemia;Cytotoxic Agents Antidepressants;Ser otonin- Norepinephrine Reuptake Inhibitors (SNRIs) (ADHD) Agent - Selective Alpha Adrenergic Agonists Antivirals;Hepatitis C Agent - s Medical Devices; Parenteral Therapy Supplies; Needles & Syringes Antivirals; Antiretrovirals - RTI- Nucleoside Analogues- Pyrimidines Corticosteroids; Glucocorticosteroids Immunosuppresive Agents; Inosine Monophosphate Dehydrogenase Page 2 of 5 w/ PA and QL (28 /28 days)

3 Inhibitors norgestimate/ethinyl estradiol OMNITROPE 5.8 mg polysaccharide iron 150 mg prednisone 5 mg, 10 mg paks progesterone 100 mg propranolol - all quinidine sulfate 200 mg VALSARTAN - all VYVANSE 10 mg XULANE transdermal patch Misc.; Growth Hormones Corticosteroids; Glucocorticosteroi ds Progestins Beta Blockers; Beta Blockers Non- Selective Antihypertensives;A ngiotensin II Receptor Antagonists Amphetamines Transdermal w/ PA losartan). UTILIZATION MANAGEMENT CHANGES doxycycline hyclate 100 mg 50 mg 100 mg Tetracyclines Added ST: Trial of preferred doxycycline monohydrate within the past 100 days). Page 3 of 5

4 REMOVALS FROM THE PDL amiodarone 150 mg/ml 50 mg/ml Type III azathioprine 100 mg Immunosuppressive Agents; Purine Analogs calcitriol 1 mcg/ml Misc.; Metabolic Modifiers; Hyperparathyroid Treatment - Vitamin D Analogs CELLCEPT 200 mg/ml oral suspension Immunosuppressive Agents; Inosine Monophosphate Dehydrogenase Inhibitors mycophenolate mofetil 200 mg/ml oral suspension DAPSONE 50 mg, 100 mg Anti-Infective Agents - Misc.; Leprostatics EPIVIR 10 mg/ml Antivirals;Antiretro virals-rti- Nucleoside Analogues- Pyrimidines Removed from PDL lamivudine 10 mg/ml FE C plus Agents;Hematopoiet ic Mixtures;Iron s INCIVEK 375 mg Antivirals;Hepatitis C Agents INTUNIV extendedrelease - all (ADHD) Agent - Selective Alpha Adrenergic Agonists guanfacine hydrochloride 24 hr sustained-release - all levothyroxine 100 mcg multigen Page 4 of 5

5 Agents; Mixtures; Iron s NATURE-THROID mg mg 325 mg ARMOUR THYROID procainamide 100 mg/ml 500 mg/ml propranolol hydrochloride/hydrochl orothiazide - all Antihypertensives; Antihypertensives s; Beta Blocker & Diuretic s propranolol + hydrochlorothiazide quinidine gluconate 80 mg/ml SAVELLA titration pak, - all Pyschotherapeutic and Neurological Agents - Misc.; Fibromyalgia Agent - SNRIs gabapentin, (QL may apply) TEV-TROPIN 5 mg Misc.; Growth Hormones OMNITROPE 5.8 mg THYROLAR - all levothyroxine; liothyroxine WESTHROID - all ARMOUR THYROID If you have questions, Ohana Health Plan s Pharmacy Help Desk and its affiliated vendor, Catamaran Rx, are available to assist providers at Thank you for your care of Ohana Medicaid members. Sincerely, Ohana Health Plan Pharmacy Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. Page 5 of 5

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