UPDATE WellCare s South Carolina

Transcription

1 September 3, 2015 UPDATE WellCare s South Carolina Preferred Drug List Dear Provider: At the September 3, 2015 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 (), effective November 3, Please carefully review these changes. UPPER CASE = Brand Name Drugs Lower case italics = Generic Drugs = Preferred Drug List PA = Prior Authorization Effective date of change: November 3, 2015 Key QL = Quantity Limit ST = Step Therapy AL = Age Limit YOA = Years of Age Drug Name Therapeutic Class Change acetic acid 2% otic aripiprazole - all strengths ADDITIONS TO THE Otic Added to the Antipsychotics/Anti manic bacitracin 500U/GM ointment bacitracin ophthalmic ointment bacitracin/neomycin/ polymixin ointment benzoyl peroxide 5%, 10% liquid wash Brom/PSE/Dm syrup Added to the w/ ST (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.) Added to the Added to the Added to the Added to the Added to the Alternative Page 1 of 8

2 Drug Name Therapeutic Class Change bupropion hydrochloride (smoking deterrent) 150 mg SR 12HR calcium carbonate 750 mg chewables carbamoxide 6.5% otic drops children's silfedrine 15 mg/5 ml liquid clotrimazolebetamethasone % cream dexmethylphenidate 20 mg SR 24 HR diphenydramine 12.5 mg/5 ML elixir (OTC) diphenydramine 50 mg/ml injection eye lubricant ophthalmic ointment first-lansoprazole suspension Psychotherapeutic And Neurological - Misc. Antacids Otic Decongestants ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Ulcer Drugs Added to the Added to the Added to the Added to the Added to the Added to the w/ QL 31/31 days & AL: Min 6 YOA, Max 20 YOA Added to the Added to the Added to the Added to the w/ ST: (T/F of omeprazole and ranitidine syrup) GARDASIL injection Vaccines Added to the w/ AL: Min 19 YOA, Max 26 YOA HUMALOG KWIK 200U/mL injection hydrocortisone/aloe 1% cream INSULIN PEN MIS 31GX4MM Antidiabetics Medical Devices Added to the w/ QL: 30 ml/30 days Added to the Added to the w/ QL: 100/31 days Alternative Page 2 of 8

3 Drug Name Therapeutic Class Change ketoralac 0.5% ophthalmic LOTEMAX 0.5% ophthalmic gel methylphenidate 10 mg extendedrelease metronidazole 0.75% gel MUCINEX 1200 mg MUCINEX-D mg mucus relief 600 mg extended-release NOVOLOG MIX 70/30 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 injection PREVNAR-13 injection ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Antidiabetics Vaccines Vaccines Page 3 of 8 Added to the Added to the Added to the w/ QL 93/31 days & AL: Min 6 YOA, Max 20 YOA Added to the Added to the Added to the Added to the Added to the w/ QL: 60 ml/31 days Added to the w/ AL: Min 19 YOA Added to the w/ AL: Min 19 YOA Alternative

4 Drug Name Therapeutic Class Change prometh VC 6.25mg/5mg/5 ml syrup pseudoephedrine 120 mg extendedrelease pyridostigmine 180 mg saline 0.65% nasal spray SANTYL 250 U/G ointment SAPHRIS 2.5 mg sublingual sodium chloride 3%, 7% nebulizer tobramycin/dexamet hasone % ophthalmic suspension ZOSTAVAX injection artificial tears 1.4% ophthalmic dextroamphetamine extended-release - all strengths duloxetine 20mg, 60mg Decongestants Antimyasthenic/Chol inergic Antipsychotics/Anti manic Vaccines Added to the Added to the Added to the Added to the Added to the w/ PA Added to the w/ ST (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.) & AL: Min 18 YOA Added to the Added to the Added to the w/ AL: Min 50 YOA UTILIZATION MANAGEMENT CHANGES Added QL: 15 ml/31 days ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Antidepressants Removed ST: Covered w/ AL Min 6 YOA, Max 20 YOA & QL 31 caps/31 days Removed ST: Covered w/ QL 62 caps/31 days Alternative Page 4 of 8

5 Drug Name Therapeutic Class Change duloxetine 30mg ABILIFY - all strengths ABSORICA 20mg, 30mg, 40mg Antidepressants Removed ST: Covered w/ QL 31 caps/31 days REMOVALS FROM THE Antipsychotics/Anti manic Page 5 of 8 Alternative aripiprazole (ST may apply) CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG acetaminophen oral tablet 500 mg acetic acid 2% otic acetic acid 2% otic acetaminophen 500 mg Analgesics - NonNarcotic ACETASOL HC otic Otic acetic Otic acid/aluminum 2% otic ACITRETIN 17.5 mg acne medication 5% benzoyl peroxide gel AFRIN 0.05% spray Decongestants pseudoephedrine hcl oral tablet 30 mg, 60 mg all day allergy 5 cetirizine hcl oral mg/5 ml syrup 1 mg/ml, 5 mg/5ml ALTARYL 12.5 mg/5 diphenydramine ml syrup 12.5 mg/5 ML elixir (OTC) BARACLUDE 1 mg Antivirals entecavir oral tablet 0.5 mg, 1 mg benzoyl peroixde benzoyl peroxide 6% lotion benzoyl peroxide benzoyl peroxide 2.5% liquid BP 10-1 emulsion benzoyl peroxide Drug Name Therapeutic Class Change Alternative

6 BP CLEANSING 4% lotion calcitriol 3 mcg/gm ointment child complete chewable allergy clemastine 0.5 mg/5 ml syrup DELSYM 5-5 mg cough lozenges EURAX 10% cream, lotion invisible acne 10% cream KLOR-CON 20meq, 25meq packets lice treatment 1% liquid MESTINON timespan metaproterenol 10 mg/5 ml syrup metipranolol 0.3% ophthalmic MYORISAN 10mg, 20mg, 40mg NAMENDA XR, titration pack XR - all strengths Mouth And Throat Minerals & Electrolytes Antimyasthenic/Chol inergic Antiasthmatics Psychotherapeutic And Neurological - Misc. Page 6 of 8 benzoyl peroxide diphenydramine 12.5 mg/5 ML elixir (OTC) diphenydramine 12.5 mg/5 ML elixir (OTC) Please reference permethrin external cream 5 % benzoyl peroxide potassium chloride oral 20 meq/15ml (10%) lice killing % shampoo pyridostigmine 180 mg albuterol sulfate oral syrup levobunolol hcl ophthalmic ; timolol maleate ophthalmic CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG memantine oral 5mg,10mg Drug Name Therapeutic Class Change Alternative

7 naproxen 500 mg delayed-release nasal decongestant 10 mg promethazine 12.5mg mg, 50 mg suppositories promethazine 25 mg/ml, 50 mg/ml injection pyrethins-piperonyl butoxide external liquid % Analgesics - Anti- Inflammatory Decongestants RID liquid salivasure lozenges Mouth And Throat sodium fluoride 0.2% mint sodium fluoride 0.2% sodium sulfacetamide-sulfur 10-5% cream, lotion TASMAR 100 mg tolnaftate 1% trazodone 300 mg Mouth And Throat Mouth And Throat Antiparkinson Antidepressants naproxen sodium oral tablet 275 mg, 550 mg pseudoephedrine hcl oral tablet 30 mg, 60 mg Promethazine 25mg suppositories Promethazine 25mg suppositories lice killing % shampoo lice killing % shampoo pilocarpine hcl oral tablet 5 mg, 7.5 mg sodium fluoride oral 1.1 (0.5 f) mg/ml sodium fluoride oral 1.1 (0.5 f) mg/ml sulfacetamide sodium external suspension 10 % Please reference trazodone hcl oral tablet 100 mg, 150 mg, 50 mg If you have questions, WellCare s Pharmacy Help Desk and its affiliated vendor, Catamaran, are available to assist providers at Thank you for your care of WellCare s South Carolina Medicaid members. Page 7 of 8

8 Sincerely, WellCare Health Plans, Inc. Page 8 of 8