UPDATE WellCare s New Jersey

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1 UPDATE WellCare s New Jersey Preferred Drug List July 13, 2015 Dear Provider: At the June 04, 2015 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare s New Jersey Medicaid Preferred Drug List (PDL), effective August 15, Please carefully review these changes. UPPER CASE = Brand Name Drugs Lower case italics = Generic Drugs PDL = Preferred Drug List PA = Prior Authorization Effective date of change: August 15, 2015 Key QL = Quantity Limit ST = Step Therapy AL = Age Limit YOA = Years of Age Drug Name Therapeutic Class Change acetaminophen 650 mg suppositories amphetamine/dextroam phetamine extendedrelease - all strengths aspirin 81 mg enteric coated bacitracin-neomycinpolymyxin ointment bicalutamide 50 mg bismuth subsalicylate 262 mg/15 ml suspension bupropion 150 mg SR 12HR Analgesics - Nonnarcotic ADDITIONS TO THE PDL Analgesics - Nonnarcotic Dermatologicals Antidiarrheals w/ QL (62 caps/31 days) & AL: Min 6 YOA, Max 20 YOA PDL Alternative (if

2 calcium carbonate 750 mg chewable Antacids clozapine 12.5 mg orally disintegrating doxepin 150 mg nic Agents w/ QL (31 tabs/31 days) & AL: Min 18 YOA double antibiotic ,000 unit/gm ointment Dermatologicals duloxetine 20 mg, 60 mg duloxetine 30 mg fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg patches HUMIRA psoriasis pen kit INVEGA SUSTENNA injections Analgesics - Opioid Analgesics - Anti- Inflammatory nic Agents w/ QL (62 caps/31 days) & ST (trial of preferred SSRI, gabapentin, amitriptyline, or venlafaxine). w/ QL (31 caps/31 days) & ST (trial of preferred SSRI, gabapentin, amitriptyline, or venlafaxine). & QL (10 patches/30 days) w/ PA, QL & AL : 117 mg/0.75 ml: QL: 0.75 ml/28 days, AL: 156 mg/ml: QL: 1 ml/28 days, AL: Min 18 YOA 234 mg/1.5 ml: QL: 1.5 ml/28 days, AL: 39 mg/0.25 ml: QL: 0.25 ml/28 days, AL: 78 mg/0.5 ml: QL:

3 0.5 ml/28 days, AL: KALYDECO 50 mg, 75 mg granules melatonin maximum strength 5 mg methylphenidate hydrochloride chewable - all strengths nicotine polacrilex 2 mg, 4 mg mint lozenges norethindrone & ethinyl estradiol-fe 0.8 mg-25 mcg chewable ONCASPAR 750 mg/ml injection probenecid/colchicine 500mg 0.5mg Respiratory Agents - Misc. Alternative Medicines Contraceptives Gout Agents w/ AL: Min 6 YOA w/ QL (620 lozenges/31 days) RENA-VITE Multivitamins rizatriptan 5 mg, 10 mg Migraine Products w/ AL: Min 6 YOA, Max 17 YOA UTILIZATION MANAGEMENT CHANGES atovaquone 750 mg/5 ml suspension enoxaparin sodium injections - all strengths Anti-Infective Agents - Misc. Anticoagulants Added PA Updated QL: 300 mg/3 ml: QL: 93 ml/31 days 100 mg/ml: QL: 31 ml/31 days 150 mg/ml: QL: 31 ml/31 days 120 mg/0.8 ml: QL: 24.8 ml/31 days 80 mg/0.8 ml: QL: 24.8 ml/31 days 30 mg/0.3 ml: QL: 9.3 ml/31 days 40 mg/0.4 ml: QL:

4 12.4 ml/31 days 60 mg/0.6 ml: QL: 18.6 ml/31 days SAPHRIS SUB 5 mg, 10 mg nic agents Updated AL: Min 10 YOA spinosad 0.9% topical suspension Dermatologicals Updated AL: Min 6 months of age ADDERALL XR - all strengths ADRUCIL 500 mg/10ml injection REMOVALS FROM THE PDL amphetamine/dextr oamphetamine extended-release - all strengths (QL, AL may apply) fluorouracil 500 mg/10ml solution ENDOMETRIN 100 mg suppositories Vaginal Products progesterone 100 mg ERWINAZE 10,000U injection GENERESS FE chewable Contraceptives norethindrone & ethinyl estradiol-fe 0.8 mg-25 mcg chewable METHYLIN chewable - all strengths methylphenidate hcl chewable tabs - all strengths (AL may apply) naproxen 500 mg delayed-release Analgesics - Anti- Inflammatory naproxen 250 mg, 375 mg, 500 mg sponge 1000 mg vaginal Vaginal Products SAVELLA - all strengths duloxetine (ST, QL may apply); gabapentin (QL may apply)

5 If you have questions, WellCare s Pharmacy Help Desk and its affiliated vendor, Catamaran, are available to assist providers Thank you for your care of WellCare s New Jersey members. Sincerely, WellCare Health Plans, Inc.

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