Key ADDITIONS TO THE PDL. Antineoplastics and Adjunctive Therapies; Antimetabolites. Antiparkinson Agents; Antiparkinson Dopaminergics

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1 July 15, 2014 Dear Provider: UPDATE WellCare of South Carolina Preferred Drug List At the April 24, 2014 and June 26, 2014 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare of South Carolina Medicaid Preferred Drug List (), effective August 26, Please carefully review these changes. UPPER CASE = Brand Name Drugs Lower case italics = Generic Drugs = Preferred Drug List Effective date of change: August 26, 2014 Key PA = Prior Authorization QL = Quantity Limits ST = Step Therapy Drug Name Therapeutic Class Change ADRUCIL 50 mg/ml solution for injection ADDITIONS TO THE Antimetabolites Added to the w/ PA Alternative (if applicable) ALLEGRA-D 12 HOUR ALLERGY & CONGESTION amantadine hydrochloride 100 mg aspirin 81 mg enteric coated AVASTIN solution for injection all cetirizine hydrochloride hydrochloride syrup - all Decongestant & Antihistamine Antiparkinson Agents; Antiparkinson Dopaminergics Analgesics - Nonnarcotic; Salicylates Antineoplastics - Angiogenesis Inhibitors; Vascular Endothelial Growth Factor Inhibitors Antihistamines; Non- Sedating Added to the Added to the Added to the Added to the w/ PA Added to the w/ QL (300 ml/31 days) Page 1 of 18

2 Drug Name Therapeutic Class Change Alternative CHLOR-TRIMETON - all Antihistamines; Alkylamines Added to the CONDYLOX 0.5 % topical gel dexmethylphenidate hydrochloride - all diazepam 5 mg/5 ml vials, disp syringes DIMAPHEN DM COLD/COUGH CHILDRENS elixir DIMETAPP LONG ACTING COUGH PLUS COLD syrup erythromycin 2% gel escitalopram oxalate - all estazolam 1 mg 2 mg fexofenadine hydrochloride - all fluoxetine hydrochloride capsules, - all Dermatologicals; Keratolytic/Antimitotic Agents ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Stimulants Non-Narc Antitussive- Decongestant- Antihistamine Decongestant & Antihistamine Macrolides; Erythromycins Antidepressants; Selective Serotonin Reuptake Inhibitors Hypnotics; Non- Barbiturate Hypnotics; Benzodiazepine Hypnotics Antihistamines; Non- Sedating Antidepressants; Selective Serotonin Reuptake Inhibitors Added to the w/ PA Added to the w/ QL (62 /31 days) & AL (Min 6 ) Added to the Added to the Added to the Added to the Added to the Added to the Added to the Added to the fosphenytoin sodium 100 mg PE/2 ml injection Hydantoins Added to the gabapentin 250 mg/5 ml solution gemcitabine solution for injection all Antimetabolites Added to the w/ QL: 2230 ml/31 days Added to the w/ PA Page 2 of 18

3 Drug Name Therapeutic Class Change Alternative haloperidol ampules Antipyschotics/Antimani c Agents; Butyrophenones Added to the w/ AL (Min 3 ) hydrocodone polistirex/chlorpheniramine polistirex 10 mg - 8 mg/5 ml suspension haloperidol lactate oral solution 2 mg/ml solution for injection 5 mg/ml hydroxyzine hydrochloride 10 mg/5 ml syrup INVEGA SUSTENNA extended-release suspension for injection - all LEUCOVORIN CALCIUM - all levocarnitine 200 mg/ml vial levocetirizine 5 mg levocetirizine 2.5 mg/5 ml oral solution loratadine syrup/solution - all loratadine allergy relief - all lorazepam disp syringes, vials - all Opioid Antitussive- Antihistamine Antipyschotics/Antimani c Agents; Butyrophenones Antianxiety Agents Antipyschotics/Antimani c Agents; Benzisoxazoles Chemotherapy Rescue/Antidote Agents; Folic Acid Antagonists Rescue Agents Endocrine And Metabolic Agents - Misc.; Metabolic Modifiers; Carnitine Replenisher - Agents Antihistamines; Non- Sedating Antihistamines; Non- Sedating Antihistamines; Non- Sedating Antihistamines; Non- Sedating Added to the Added to the w/ AL (Min 3 ) Added to the Added to the w/ PA, AL (Min 18 ) & QL (1 syringe/28 days) Added to the Added to the Added to the Added to the w/ ST: T/F of loratadine solution AND cetirizine solution Added to the w/ QL (310 ml/31 days) Added to the Added to the Page 3 of 18

4 Drug Name Therapeutic Class Change Alternative meprobamate - all Antianxiety Agents Added to the methylin chew - all mirtazapine rapid - all nefazodone hydrochloride - all nortriptyline hydrochloride 10 mg/5ml solution PEGANONE 250 mg phenelzine sulfate 15 mg protriptyline hydrochloride - all selegiline hydrochloride 5 mg capsules SUPARTZ 1% solution for injection TRELSTAR solution for injection mg 22.5 mg TUSSICAPS extendedrelease capsules - all valproic acid solution - all zafirlukast - all ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Stimulants Antidepressants;Alpha- 2 Receptor Antagonists (Tetracyclics) Antidepressants; Serotonin Modulators Antidepressants; Tricyclic Agents Hydantoins Antipyschotics/Antimani c Agents; Monoamine Oxidase Inhibitors Antidepressants; Tricyclic Agents Antiparkinson Agents; Antiparkinson Monoamine Oxidase Inhibitors Musculoskeletal Therapy Agents; Viscosupplements Antineoplastic - Hormonal and Related Agents; LHRH Analogs Opioid Antitussive- Antihistamine Valproic Acid Leukotriene Added to the w/ AL (Min 6 ) Added to the Added to the Added to the w/ QL (2325 ml/31 days) Added to the w/ QL: 372 /31 days Added to the Added to the Added to the Added to the w/ PA Added to the w/ PA Added to the Added to the Added to the Page 4 of 18

5 Modulators; Leukotriene Receptor Antagonists Drug Name Therapeutic Class Change Alternative ZYKADIA 150 mg capsules Antineoplastics And Adjunctive Therapy; Antineoplastic Enzyme Inhibitors; Antineoplastic - Tyrosine Kinase Inhibitors Added to the w/ PA and QL: 155 capsules/31 days UTILIZATION MANAGEMENT CHANGES ABILIFY solution, - all acamprosate calcium 333 mg delayed-release AFINITOR - all albuterol sulfate 5 mg/ ml nebulizer solution albuterol sulfate 2 mg/5 ml syrup albuterol sulfate 2.5 mg/3 ml nebulizer solution Antipyschotics/Antimani c Agents; Quinolone Derivatives Agents for Chemical Dependenc y; Alcohol Deterrents Antineoplastics Enzyme Inhibitors; Antineoplastic - mtor Kinase Inhibitors Sympathomimetics; Beta Adrenergics Sympathomimetics; Beta Adrenergics Sympathomimetics; Beta Adrenergics & QL, ST: (T/F of 2: risperidone, quetiapine, olanzapine) Updated QL: 186 /31 days Updated PA Updated QL: 60 ml/30 days Updated QL: 2480 ml/31 days Updated QL: 720 ml/31 days alprazolam - all amphetamine salt combo - all ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Amphetamines;Amphet amine Mixtures, ST and QL Page 5 of 18

6 Drug Name Therapeutic Class Change Alternative ATROVENT HFA 17 mcg/ actaution inhalation aerosol Bronchodilators - Anticholinergics Updated QL: 25.8 gm/31 days benzonatate capsules - all BOSULIF 100 mg 500 mg budesonide suspension for inhalation - all bupropion hydrochloride sustained-release - all carbamazepine 100 mg/5 ml suspension chlorpromazine - all clorazepate - all COMBIVENT RESPIMAT 20 mcg-100 mcg/actuation inhalation solution cromolyn sodium 20 mg/2 ml nebulizer solution cyproheptadine hydrochloride 2 mg/5 ml syrup DELSYM controlled release liquid dextroamphetamine sulfate 5 mg Antitussive - Nonnarcotic Antineoplastics Enzyme Inhibitors; Tyrosine Kinase Inhibitors Steroid Inhalants Antidepressants Antipyschotics/ Antimanic Agents; Phenothiazines Sympathomimetics; Adrenergic Combinations Nasal Agents - Systemic and Topical; Nasal Antiallergy; Nasal Mast Cell Stabilizers Antihistamines; Piperidines Antitussive - Nonnarcotic ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Updated PA Updated QL and AL: QL 120 ml/31 days and AL Max 8 Updated QL: 2480 ml/31 days Added AL: Min 6 months of age Added AL: Min 9 Updated QL: 4 gm/20 days Updated QL: 300 ml/31 days, ST and QL Page 6 of 18

7 10 mg Amphetamines Drug Name Therapeutic Class Change Alternative diazepam - all diazepam rectal gel - all divalproex sodium 500 mg extended-release divalproex sodium 250 mg extended-release divalproex sodium 500 mg delayed-release enteric coated divalproex sodium delayed-release enteric coated - all donepezil 10 mg 2.5 mg DULERA inhalation aerosol - all ethosuximide 250 mg/5 ml solution EXELON patches - all fluphenazine hydrochloride - all fluphenazine 2.5 mg/5 ml elixir fondaparinux sodium 2.5 mg/0.5 ml subcutaenous solution - Valproic Acid Valproic Acid Valproic Acid Valproic Acid Antidementia Agents; Cholinomimetics - ACHE Inhibitors Sympathomimetics; Adrenergic Combinations Succinimides Neurological Agents;Antidementia Agents;Cholinomimeti cs - ACHE Inhibitors Antipyschotics/ Antimanic Agents; Phenothiazines Antipsychotics/ Antimanic Agents; Phenothiazines Anticoagulants; Heparins and Heparinoid-Like Agents; Synthetic Heparinoid-Like Agents Updated QL: 3 each/31 days Updated QL: 279 /31 days Updated QL: 310 /31 days Updated QL: 279 /31 days Added QL: 13 gm/30 days Updated QL: 930 ml/31 days Updated AL: Min 18 Added QL: QL 2480 ml/31 days and AL: min 18 Updated QL: 16 ml/31 days Page 7 of 18

8 Drug Name Therapeutic Class Change Alternative fondaparinux sodium 5 mg/0.4 ml subcutaenous solution fondaparinux sodium 7.5 mg/0.6 ml subcutaenous solution fondaparinux sodium 10 mg/0.8 ml subcutaenous solution Anticoagulants; Heparins and Heparinoid-Like Agents; Synthetic Heparinoid-Like Agents Anticoagulants; Heparins and Heparinoid-Like Agents; Synthetic Heparinoid-Like Agents Anticoagulants; Heparins and Heparinoid-Like Agents; Synthetic Heparinoid-Like Agents Updated QL: 5.6 ml/31 days Updated QL: 8.4 ml/31 days Updated QL: ml/31 days FORADIL AEROLIZER 12 mcg capsules GLEEVEC - all guaifenesin - all guaifenesin liquid/solution haloperidol - all haloperidol decanoate ampules, vials - all hydrocodone bitartrate/homatropine methylbromide syrup, hydrocodone/apap 7.5 mg-650 mg 10 mg-650 mg 10 mg-660 mg hydrocodone/apap 10 mg-750 mg 7.5 mg-750 mg Sympathomimetics; Beta Adrenergics Antineoplastics Enzyme Inhibitors;Antineoplastic - Tyrosine Kinase Inhibitors Expectorants Expectorants Antipyschotics/ Antimanic Agents; Butyrophenones Antipyschotics/ Antimanic Agents; Butyrophenones Antitussive - Opioid Analgesics - Opioid;Opioid Combinations;Hydroco done Combinations Analgesics - Opioid;Opioid Combinations;Hydroco done Combinations Updated QL: 60 capsules/30 days Updated PA and Added AL: Min 3 Added AL: Min 18 Updated QL: 186 /31 days Updated QL: 165 /31 days Page 8 of 18

9 Drug Name Therapeutic Class Change Alternative ICLUSIG Antineoplastics Enzyme 15 mg Inhibitors;Antineoplastic 45 mg - Tyrosine Kinase Added PA Inhibitors ipratropium bromide/albuterol sulfate 0.5 mg-3 mg/3 ml nebulizer solution lamotrigine chew - all lamotrigine 25 mg lamotrigine 100 mg 150 mg 200 mg levetiracetam 250 mg levetiracetam 500 mg 750 mg 1000 mg levetiracetam 100 mg/ml solution lorazepam - all loxapine capsules - all megestrol 40 mg/ml suspension methylphenidate hydrochloride extendedrelease 18 mg 27 mg Antipyschotics/ Antimanic Agents; Dibenzapines Hormonal and Related Agents; Progestins - Antineoplastic ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Stimulants Updated QL: 720 ml/31 days Updated QL: 310 /31 days Updated QL: 310 /31 days Updated QL: 372 /31 days Added AL: Min 18 Added QL: 600 ml/31 days Updated QL: 62 /31 days methylphenidate hydrochloride 10 mg extended-release ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Stimulants & Updated AL: Min 6 Page 9 of 18

10 Drug Name Therapeutic Class Change Alternative methylphenidate hydrochloride 20 mg methylphenidate hydrochloride 5 mg 10 mg montelukast sodium 4 mg packets montelukast sodium, chewables - all NAMENDA solution,, tablet dosepak - all nicotine patches - all ORAP - all oxazepam capsules - all oxcarbazepine - all oxcarbazepine 300 mg/5 ml suspension perphenazine - all phenytoin suspension - all pramipexole dihydrochloride - all ADHD/Anti-Narcolepsy/ Anti-Obesity/ Anorexiants; Stimulants ADHD/Anti-Narcolepsy/ Anti-Obesity/ Anorexiants; Stimulants Leukotriene Modulators; Leukotriene Receptor Antagonists Leukotriene Modulators; Leukotriene Receptor Antagonists Antidementia Agents; N-Methyl-D-Aspartate (NMDA) Receptor Antagonists Smoking Deterrents Neurological Agents Antipyschotics/ Antimanic Agents; Phenothiazines Hydantoins Antiparkinson Agents; Antiparkinson Dopaminergics; Nonergoline Dopamine Updated QL: 93 /31 days and Added AL: Max 2 Updated QL: 70 patches/365 days Added AL: Min 12 Updated QL: 248 /31 days Added AL: Min 12 Updated QL: 930 ml/31 days Added ST: T/F ropinirole within the past 100 days. Page 10 of 18

11 Receptor Agonists Drug Name Therapeutic Class Change Alternative prochlorperazine maleate 10 mg 5 mg rectal suppository 25 mg PROLIA 60 mg/ml solution for injection PULMICORT suspension for inhalation - all quetiapine fumarate - all risperidone rapid - all rivastigmine capsules - all ROBITUSSIN CHILDRENS COUGH LONG-ACTING syrup SAPHRIS sublingual 10 mg 5 mg STIVARGA 40 mg SYMBICORT inhalation aerosol - all temazepam capsules - all Antipyschotics/Antimani c Agents; Phenothiazines Endocrine And Metabolic Agents - Misc.; Bone Density Regulators; RANK Ligand (RANKL) Inhibitors Steroid Inhalants Antipyschotics/ Antimanic Agents; Dibenzapines Antipyschotics/ Antimanic Agents;Benzisoxazoles Antidementia Agents; Cholinomimetics - ACHE Inhibitors Antitussive - Nonnarcotic Antipyschotics/ Antimanic Agents; Dibenzapines; Dibenzooxepino Pyrroles Antineoplastic Enzyme Inhibitors; Antineoplastic - Multikinase Inhibitors Sympathomimetics; Adrenergic Combinations Hypnotics;Non- Barbiturate; Added AL: Min 2 Removed ST and Added PA Updated QL and AL: QL 120 ml/31 days and AL Max 8 Added AL: Min 5, QL (62 /31 days) Added AL: Min 18 ; ST: (T/F of 2: risperidone, quetiapine, olanzapine) Updated PA Updated QL: 10.2 gm/30 days Page 11 of 18

12 Benzodiazepine Hypnotics Drug Name Therapeutic Class Change Alternative thioridazine - all thiothixene capsules - all tiagabine - all tizanidine - all triazolam - all trifluoperazine - all valproic acid syrup zolpidem tartrate 5 mg 10 mg ABILIFY vials, discmelts - all Antipyschotics/Antimani c Agents; Phenothiazines Antipyschotics/Antimani c Agents; Thioxanthenes GABA Modulators GABA Modulators Hypnotics;Non- Barbiturate Hypnotics; Benzodiazepine Hypnotics Antipyschotics/Antimani c Agents; Phenothiazines Valproic Acid Hypnotics;Non- Barbiturate Hypnotics; Non-Benzodiazepine - GABA-Receptor Modulators Added AL: Min 2 Added AL: Min 12 and Added ST: T/F of baclofen tabs AND cyclobenzaprine tabs & Added AL: Min 18 Added AL: Min 6 Updated QL: 2790 ml/31 days Added AL: Min 18 REMOVALS FROM THE Antipyschotics/Antimanic Agents;Quinolone Derivatives risperidone (QL,AL), quetiapine (QL,AL), olanzapine (QL,AL) AFINITOR DISPERZ for suspension - all Antineoplastics Enzyme Inhibitors; Antineoplastic - mtor Kinase Inhibitors AFINITOR (PA) aller-chlor 2 mg/5 ml syrup Antihistamines; Alkylamines CHLOR-TRIMETON BANZEL - all benztropine mesylate 2 mg/2 ml solution for Antiparkinson Agents; Antiparkinson lamotrigine (QL), divalproex (QL), topiramate (QL) trihexyphenidyl hydrochloride Page 12 of 18

13 injection Anticholinergics Drug Name Therapeutic Class Change Alternative BROTAPP liquid Decongestant & Antihistamine CHLOR-TRIMETON, pseudoephedrine caffeine citrate solution, vials - all ADHD/Anti-Narcolepsy /AntiObesity/Anorexiants ; Analeptics carbamazepine extended-release, capsules - all cetirizine hydrochloride chew - all Antihistamines; Non- Sedating carbamazepine immediate-release (QL) cetirizine hydrochloride hydrochloride syrup (QL) CHANTIX, dosepak - all Smoking Deterrents nicotine transdermal patch (QL) chlorpheniramine maleate controlled release - all Antihistamines; Alkylamines CHLOR-TRIMETON chlorpromazine 25 mg/ml solution for injection Antipyschotics/Antimanic Agents; Phenothiazines chlorpromazine hydrochloride oral citalopram hydrobromide 10 mg/5ml solution Antidepressants;Selectiv e Serotonin Reuptake Inhibitors citalopram hydrobromide oral clemastine fumarate - all Antihistamines; Ethanolamines clemastine fumarate oral syrup COMETRIQ capsules 60 mg 100 mg 140 mg CORICIDIN HBP COUGH & COLD cyclophosphamide powder for injection 500 mg 1 GM 2 GM Antineoplastics Enzyme Inhibitors; Antineoplastic - Tyrosine Kinase Inhibitors Antihistamine-Analgesic Adjunctive Therapies;Akylating Agents;Nitrogen Mustards BOSULIF (PA), CAPRELSA (PA) cyclophosphamide DILANTIN suspension, capsules - all Hydantoins phenytoin suspension, phenytoin capsules Page 13 of 18

14 Drug Name Therapeutic Class Change Alternative DILANTIN INFATABS 50 mg chew Hydantoins phenytoin suspension, phenytoin capsules DIMETAPP COLD & ALLERGY elixir Decongestant & Antihistamine CHLOR-TRIMETON entacapone 200 mg Antiparkinson Agents; Antiparkinson COMT Inhibitors; Peripheral COMT Inhibitors famotidine 10 mg/ml intravenous solution Ulcer Drugs; H-2 Antagonists ranitidine hydrochloride injection solution fludarabine phosphate solution for injection - all Antimetabolites flurazepam hydrochloride capsules - all Hypnotics;Non- Barbiturate Hypnotics; Benzodiazepine Hypnotics temazepam capsules FORFIVO 450 mg extended-release guaifenesin extendedrelease - all INCIVEK 375 mg Antidepressants Expectorants Antivirals; Hepatitis Agents; Hepatitis C Agents bupropion hydrochloride extended-release (XL) tablet 24 HR INLYTA 1 mg 5 mg Antineoplastics Enzyme Inhibitors; Antineoplastic - Tyrosine Kinase Inhibitors INTRON-A vials - all Antineoplastics Misc SYLATRON subcutaneous kit (PA) INTUNIV extendedrelease - all ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Attention-Deficit/ Hyperactivity Disorder (ADHD); ADHD Agent - Selective Alpha Adrenergic Agonists Clonidine hydrochloride, guanfacine hydrochloride Page 14 of 18

15 Drug Name Therapeutic Class Change Alternative LAMICTAL starter kit, chew - all levalbuterol hydrochloride nebulizer solution - all LYRICA capsules, solution - all MATULANE 50 mg capsules methylphenidate hydrochloride extendedrelease (LA) capsules, extended-release 24 hr capsules - all Sympathomimetics; Beta Adrenergics Antineoplastics Misc ADHD/Anti-Narcolepsy/ Anti-Obesity/ Anorexiants;Stimulants lamotrigine oral tablet chewable (QL) albuterol sulfate inhalation nebulization solution (QL) gabapentin oral capsules (QL) methylphenidate hydrochloride extended-release oral (QL, AL) MUCINEX MAXIMUM STRENGTH Expectorants NEO-SYNEPHRINE Vasopressors AFRIN nasal spray solution NEXAVAR 200 mg Antineoplastic Enzyme Inhibitors; Antineoplastic - Multikinase Inhibitors NICOTROL 10 mg inhaler NICOTROL NS 0.5 mg/actuation nasal spray NOHIST-LQ liquid NOVOPEN device NUEDEXTA capsules Smoking Deterrents Smoking Deterrents Decongestant & Antihistamine Medical Devices; Parenteral Therapy Supplies; Needles & Syringes Pseudobulbar Affect (PBA) Agents; Pseudobulbar Affect nicotine transdermal patches (QL), nicotine polacrilex mouth/throat lozenges (QL) nicotine transdermal patches (QL), nicotine polacrilex mouth/throat lozenges (QL) Page 15 of 18

16 Agent Combinations Drug Name Therapeutic Class Change Alternative orphenadrine citrate 100 mg extended-release Musculoskeletal Therapy Agents; Central Muscle Relaxants cyclobenzaprine hydrochloride oral tablet (QL) phenobarbital 20 mg/5 ml elixir Hypnotics;Barbiturate Hypnotics phenobarbital 20 mg/5 ml oral solution PHENYTEK capsules - all Hydantoins phenytoin sodium extended-release oral capsules phenytoin infatabs 50 mg chew Hydantoins phenytoin sodium 50 mg chewable oral tablet POTIGA - all lamotrigine (QL), divalproex (QL), topiramate (QL), carbamazepine immediate release (QL) PRANDIMET - all Antidiabetics; Antidiabetic Combinations; Meglitinide-Biguanide Combinations PRANDIN - all Antidiabetics; Meglitinide Analogues PRISTIQ extendedrelease - all Antidepressants;Seroton in-norepinephrine Reuptake Inhibitors venlafaxine hydrochloride 24 hour extended-release capsule (QL) prochlorperazine edisylate solution for injection 10 mg/2 ml 5 mg/ml Antipyschotics/Antimanic Agents; Phenothiazines fluphenazine decanoate 25 mg/ml solution for injection PROMETHAZINE VC PLAIN syrup Decongestant & Antihistamine PULMICORT FLEXHALER powder for inhalation - all Steroid Inhalants FLOVENT diskus inhalation aerosol powder (QL) RA IBU-PROFEN COLD/SINUS Decongestant-Analgesic RISPERDAL CONSTA disp syringes - all Antipyschotics/Antimanic Agents; Benzisoxazoles INVEGA SUSTENNA intramuscular suspension (QL, AL) Page 16 of 18

17 Drug Name Therapeutic Class Change Alternative SABRIL, packets - all GABA Modulators tiagabine hydrochloride oral (ST) STRATTERA capsules - all ADHD/Anti-Narcolepsy/ Anti-Obesity/ Anorexiants; Attention- Deficit /Hyperactivity Disorder (ADHD); ADHD Agent - Selective Norepinephrine Reuptake Inhibitor methylphenidate hydrochloride extended-release oral (QL, AL) TARGRETIN 75 mg capsules Antineoplastic Misc; Selective Retinoid X Receptor Agonists TEGRETOL, suspension - all carbamazepine oral suspension, carbamazepine oral (QL) THEO-24 capsules - all Xanthines theophylline extendedrelease oral tobramycin 300 mg/5 ml nebulizer solution Aminoglycosides BETHKIS 300 mg/5 ml inhalation nebulization solution (PA) TRETINOIN 10 mg capsules Retinoids venlafaxine extendedrelease - all VIMPAT - all vitamin B-12 1,000 mcg Antidepressants;Seroton innorepinephrine Reuptake Inhibitors Hematopoietic Agents venlafaxine hydrochloride 24 hour extended-release capsule (QL) lamotrigine (QL), divalproex (QL), topiramate (QL), carbamazepine immediate release (QL) VOTRIENT 200 mg Enzyme Inhibitors; Tyrosine Kinase Page 17 of 18

18 Inhibitors Drug Name Therapeutic Class Change Alternative XENAZINE - all Movement Disorder Drug Therapy zaleplon capsules 5 mg 10 mg Hypnotics;Non- Barbiturate; Non- Benzodiazepine - GABA-Receptor Modulators zolpidem tartate (QL, AL) ziprasidone capsules - all Antipyschotics/Antimanic Agents; Antipsychotics risperidone (QL,AL), quetiapine (QL,AL), olanzapine (QL,AL) If you have questions, WellCare of South Carolina s Pharmacy Help Desk and its affiliated vendor, Catamaran, are available to assist providers seven days a week, 24 hours a day at Thank you for your care of WellCare of South Carolina Medicaid members. Sincerely, WellCare of South Carolina Page 18 of 18