acyclovir 5% ointment Added to the PDL General PDL update ST: Must fail preferred oral acyclovir or valacyclovir within the past 100 days

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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 03/05/2015. 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: 05/15/2015 DRUG NME RESON FOR Requirements/Limits/lternatives acyclovir 5% ointment ST: Must fail preferred oral acyclovir or valacyclovir within the past 100 days alendronate 70 mg/75 ml Removed from the PDL alendronate sodium oral solution alendronate Removed QL Safety Concerns 10 mg 40 mg 70 mg amiodarone injection Removed from the PDL 150 mg/ml 50 mg/ml BENICR - all ST: Trial of losartan and valsartan CELLCEPT 200 mg/ml oral suspension Removed from the PDL mycophenolate mofetil 200 mg/ml oral suspension chateal 0.15 mg-30 mg Removed QL Safety Concerns chlorothiazide 500 mg injection Removed from the PDL clopidogrel 300 mg Removed from the PDL clopidogrel 75 mg

2 DRUG NME RESON FOR colchicine 0.6 mg Requirements/Limits/lternatives COUMDIN - all Removed from the PDL warfarin DE-CHLOR DM liquid Removed from the PDL desogestrel/ethinyl estradiol digox mg, mg Removed from the PDL digoxin oral tablet mg, mg doxycycline hyclate 100 mg capsules 50 mg 100 mg dded ST Safety Concerns ST: Trial of doxycycline monohydrate capsules within the past 100 days doxycycline hyclate 20 mg doxycycline monohydrate 50 mg, 100 mg capsules drospirenone/ethinyl estradiol 3.0 mg-0.03 mg DROXI capsules - all EPIVIR 10 mg/ml oral solution Removed from the PDL lamivudine 10 mg/ml oral solution feosol 45 mg Removed from the PDL ferrous sulfate oral ferrous fumarate 325 mg ferrous sulfate 220 mg/5 ml liquid DRUG NME RESON FOR Requirements/Limits/lternatives

3 glipizide-metformin hydrochloride mg HRVONI 90 mg mg P QL: 28 /28 days heather 0.35 mg Removed QL Safety Concerns insupen mis 33Gx4mm JUXTPID capsules - all Removed from the PDL KORLYM 300 mg Removed from the PDL lamivudine 10 mg/ml oral solution LNOXIN mg mg Removed from the PDL digoxin oral tablet mg, mg injection 0.25 mg/ml levonorgestrel/ethinyl estradiol 0.1 mg-0.02 mg liothyronine 10 mcg/ml injection Removed from the PDL LUMIZYME 50 mg injection P MESEHIST DM liquid Removed from the PDL metformin 1,000 mg extendedrelease Removed from the PDL metformin oral methylprednisolone - all metoprolol tartate 25 mg MOZOBIL 24 mg/1.2 ml solution Removed from the PDL for injection mycophenolate mofetil 200 mg/ml oral suspension mycophenolic 180 mg delayedrelease Removed from the PDL NTURE-THROID mg mg Removed from the PDL RMOUR THYROID

4 325 mg DRUG NME RESON FOR Requirements/Limits/lternatives NEORL solution, capsules - all Removed from the PDL cyclosporine oral solution, capsules NICIN extended-release Removed from the PDL no flush niacin oral tablet 500 mg 750 mg 1,000 mg NORDITROPIN 30 mg/3 ml Removed from the PDL OMNITROPE 5.8 mg injection (P) injection norgestimate/ethinyl estradiol QL Removed Safety Concerns OMNITROPE 5.8 mg injection P PLN-B 1.5 mg Removed QL Safety Concerns polysaccharide iron 150 mg capsules prednisone 5 mg, 10 mg paks progesterone 100 mg capsules propranolol oral solution - all propranolol 1 mg/ml injection propranolol hydrochloride/hydrochlorothiazide Removed from the PDL propranolol hydrochloride + hydrochlorothiazide - all quinidine sulfate 200 mg SVELL titration pak, - all Removed from the PDL gabapentin, capsules (QL may apply) SENSIPR - all Removed from the PDL sotalol af 120 mg SYNTHROID - all Removed from the PDL levothyroxine sodium taron forte capsules Removed from the PDL poly-iron 150 forte oral capsule mg-mcg-mg TEV-TROPIN 5 mg injection Removed from the PDL OMNITROPE 5.8 mg injection (P) THYROLR - all Removed from the PDL levothyroxine, liothyronine

5 DRUG NME RESON FOR torsemide 5 mg Requirements/Limits/lternatives TRI-DEX PE liquid Removed from the PDL VLCYTE 450 mg Removed from the PDL VLSRTN - all ST: Trial of losartan vitamin B mcg sublingual 1,000 mcg VYVNSE 10 mg capsules QL: 31 /31 days L: Min 6 YO, Max 20 YO WESTHROID - all Removed from the PDL RMOUR THYROID XULNE transdermal patch Removed QL Safety Concerns Generic Drugs italics BRND DRUGS C PS PDL Preferred Drug List P Prior uthorization Q L Quantity Limit ST Step Therapy L ge Limit YO Years of ge