WellCare of South Carolina Preferred Drug List Update

WellCare of 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 August 21, 2014. Please look at these changes. Call WellCare of South Carolina Customer Service at 1-888-588-9842 if you have any questions. You can view an updated version of the complete preferred drug list. It is on our website at https://southcarolina.wellcare.com/member/pharmacy. You can ask for a printed copy to be mailed to you. Just call Customer Service for help. Date of Change: November 21, 2014 ABSORICA capsules 20 mg 30 mg 40 mg DRUG NAME DESCRIPTION OF CHANGE REASON FOR CHANGE Requirements/Limits/Alternatives QL: (62 capsules/31 days) AL: (Min 12 YOA, Max 20 YOA) Removed PA and Added QL, AL, and ST ST: T/F preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks ACEPHEN suppositories 120 mg 325 mg 650 mg acetaminophen 160 mg/5 ml elixir Q-PAP 160 mg/5 ml child suspension acetic acid 2% otic solution ACITRETIN capsules 10 mg 25 mg ADACEL suspension for injection allopurinol 500 mg solution for injection allopurinol tablet ALPHAGAN P 0.1% ophthalmic solution brimonidine tartrate solution amcinonide 0.1% ointment betamethasone valerate ointment, fluocinonide ointment SC022513_CAD_LTR_ENG State Approved 09112013 WellCare 2013 SC_04_13 52715

ammonium lactate 12 % cream Added QL QL: 400 gm/31 days AMNESTEEM 10 mg capsules Removed PA and Added QL, AL, and ST QL: (62 capsules/31 days) AL: (Min 12 YOA, Max 20 YOA) ST: T/F preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks ANECREAM 4% cream lidocaine cream anti-fungal 2% spray, powder apraclonidine 0.05% ophthalmic solution brimonidine tartrate solution ARCALYST 220 mg powder for injection ascomp/codeine capsules Updated QL QL: 180 tablets/30 days aspirin adult tablets 81 mg suppository aspirin 81 mg enteric coated tablets 300 mg aspirin 500 mg enteric coated tablets aspirin suppositories 60 mg 120 mg 200 mg aspirin low 81 mg enteric coated tablets ATRALIN 0.05% gel tretinoin gel QL, AL azelastine 0.05% ophthalmic solution cromolyn sodium solution AZOPT 1% ophthalmic suspension bacitracin 500 unit/gm ointment benzoyl peroxide 2.5% gel benzoyl peroxide external 10 %, 5 % betamethasone dipropionate (augmented) 0.05% gel, lotion, ointment betamethasone dipropionate cream

BETIMOL ophthalmic solution - all strengths timolol maleate solution BLEPHAMIDE S.O.P 0.2%-10% ophthalmic ointment sulfacetamide prednisolone solution BOOSTRIX suspension for injection brimonidine 0.15% ophthalmic solution buprenorphine sublingual tablets - all strengths Removed QL CAFERGOT 1 mg-100 mg tablets CARAC 0.5% cream fluorouracil cream carbamide peroxide 6.5% otic solution CELEBREX capsules - all strengths Updated QL QL: 31 capsules/31 days chlorhexidine gluconate 0.12% solution Added QL QL: 480 ml/31 days choline magnesium trisalicylate tablets 1,000 mg liquid 500 mg/5 ml CICLOPIROX 0.77% cream, suspension CLARAVIS capsules 20 mg 30 mg 40 mg Removed PA and Added QL, AL, and ST QL: (62 capsules/31 days) AL: (Min 12 YOA, Max 20 YOA) ST: T/F preferred oral antibiotics for at least 6-8 weeks; Max duration of therapy 20 weeks clobetasol propionate 0.05% solution fluocinonide solution clotrimazole/betamethasone dipropionate 1% 0.05% cream, lotion cortizone-10 eczema lotion cyclopentolate 1% ophthalmic solution atropine ophthalmic solution

CYSTARAN 0.44% ophthalmic solution DENAVIR 1% cream ST: T/F oral acyclovir or valacyclovir within the past 100 days desonide 0.05% ointment alclometasone dipropionate cream dexamethasone phosphate 0.1% ophthalmic solution Removed QL diclofenac 100 mg extended-release tablets diclofenac potassium 50 mg tablets diflunisal 500 mg tablets dihydroergotamine mesylate solution for injection 1 mg/ml nasal spray 4 mg/ml DOLOPHINE 10 mg tablets sumatriptan spray DRITHO-CRÈME HP 1% cream DULERA aerosol inhalation - all strengths Removed ST PA QL: 248 tablets/30 days ELIDEL 1% cream Updated QL QL: 30 GM/30 days EYE ALLERGY relief solution cromolyn sodium solution fentanyl 100 mcg/hr transdermal patch PA Added PA & Updated QL QL: 10 patches/30 days FEVERALL infant suppositories 120 mg 325 mg 80 mg FINACEA 15% gel erythromycin-benzoyl peroxide gel

FLAREX 0.1% ophthalmic suspension fluorometholone ophthalmic suspension fluocinolone acetonide oil 0.01% ear drops fluorometholone 0.1% ophthalmic ointment fluorometholone ophthalmic suspension FLUOROPLEX 1% cream fluorouracil cream flurbiprofen tablets - all strengths FROVA 2.5 mg tablets sumatriptan succinate tablet (QL) GEL-KAM 0.4% gel dentagel, karigel GERI-HYDROLAC 5% lotion ammonium lactate 12 % cream (QL) hydrocodone/ibuprofen 7.5 mg-200 mg tablets QL: 150 tablets/30 days hydrocortisone cream 0.5% 2.5% ointment hydrocortisone 1% cream, ointment 0.5% hydrocortisone acetate 25 mg suppositories hydrocortisone butyrate 0.1% cream, ointment, solution hydrocortisone valerate cream hydrocortisone valerate 0.2% ointment HYDROSKIN 1% lotion hydroxypropyl methylcellulose 0.3% ophthalmic solution ILARIS 180 mg powder for injection indomethacin 75 mg extended-release capsules indomethacin oral capsule 25 mg, 50 mg isopto homatropine 2% ophthalmic solution brimonidine tartrate solution

isopto hyoscine 0.25% ophthalmic solution ketorolac ophthalmic solution - all strengths diclofenac sodium ophthalmic soluton, flurbiprofen sodium ophthalmic solutoin LAC-HYDRIN 5% lotion ammonium lactate 12 % cream (QL) LAMISIL AT 1% spray terbinafine cream LATUDA tablets - all strengths lidocaine oral 4% solution quetiapine, olanzapine or risperidone (AL, QL may apply) lidocaine solution for injection 0.5 % 1% 1.5% 2% lidocaine 4% cream lidocaine 5% ointment LMX 4% cream lidocaine 5% ointment LOTEMAX 0.5% ophthalmic solution MAXIDEX 0.1% ophthalmic solution meloxicam tablets - all strengths Removed QL meperidine tablets, solutions - all strengths morphine, hydromrphone tablet methadone oral solution 5 mg/5 ml 10 mg/5 ml methotrexate solution for injection 1 gm/40 ml 50 mg/2 ml 250 mg/10 ml metipranolol hydrochloride 0.3% ophthalmic solution metronidazole 0.75% gel, lotion metronidazole cream MICATIN 2% aerosol terbinafine cream

MIGERGOT 100 mg-2 mg suppository mometasone furoate 0.1% solution mometasone furoate ointment morphine sulfate solution for injection - all strengths morphine sulfate 10 mg/5 ml oral solution nabumetone tablets - all strengths NAPHCON A ophthalmic solution cromolyn sodium solution naproxen 125 mg/5 ml suspension Added QL QL: 2000 ml/31 days neomycin/polymyxin/bacitricin/hydrocortisone neomycin-polymyxin-dexameth ophthalmic ointment ophthalmic ointment neomycin/polymyxin/hydrocortisone ophthalmic suspension NORITATE 1% cream metronidazole external cream NUCYNTA extended-release tablets - all strengths nystatin 10,000 u/ml suspension Added QL QL: 300 ml/31 days nystatin/triamcinolone acetonide 100000unit/g-0.1% cream, ointment OLYSIO 150 mg capsules OXSORALEN-ULTRA 10 mg capsules PA QL: 28 capsules/28 days oxycodone 30 mg tablets Added QL QL: 240 tablets/30 days oxycodone tablets 5 mg 15 mg 20 mg Updated QL QL: 240 tablets/30 days oxycodone 10 mg tablets QL: 240 tablets/30 days oxycodone 5 mg capsules Updated QL QL: 240 capsules/30 days oxycodone 20 mg/ml concentrated solution oxycodone 5mg/5ml solution

oxycodone/apap tablets 7.5 mg-325 mg 10 mg -325 mg QL: 248 tablets/31 days OXYCONTIN extended-release tablets oxycodone hcl, methadone hcl, 10 mg 15 mg 20 mg 30 mg morphine tablet 40 mg 60 mg 80 mg OXYMORPHONE extended-release tablets - all morphine, oxycodone hcl, strengths hydromorphone hcl tablet pain reliever plus tablets ascomp/codeine capsules pentazocine/naloxone 50 mg-0.5 mg tablets QL: 248 tablets/31 days permethrin 5% cream Updated QL QL: 60 GM/31 days permethrin 1% lotion Added QL QL: 60 ml/31 days phenylephrine hydrochloride ophthalmic solution - all strengths PHOSPHOLINE IODIDE 0.125% ophthalmic powder for reconstitution pilocarpine ophthalmic solution - all strengths PILOPINE HS 4% ophthalmic gel PRED MILD 0.12% ophthalmic suspension PRED-G S.O.P 0.3%-0.6% ophthalmic ointment brimonidine tartrate ophthalmic solution brimonidine tartrate ophthalmic solution prednisolone acetate ophthalmic suspension 1 % gentamicin sulfate ophthalmic ointment 0.3 % prednicarbate 0.1% cream, ointment triamcinolone cream or ointment prednisone sodium phosphate 1% ophthalmic solution prednisolone acetate ophthalmic suspension 1 % PROTOPIC ointment - all strengths clobetasol propionate ointment SC022513_CAD_LTR_ENG State Approved 09112013 WellCare 2013 SC_04_13 52715

Q-PAP 160 mg/5 ml child suspension RECTIV 0.4% ointment REMEVEN 50% cream RESTASIS 0.05% ophthalmic emulsion RETIN-A 0.025% cream Added QL QL: 45 GM/31 days rizatriptan tablets - all strengths sumatriptan succinate tablet (QL) rizatriptan 10 mg orally disintegrating tablets sumatriptan succinate tablet (QL) salsalate tablets - all strengths SCALP RELIEF 3% liquid selenium sulfide 2.25% shampoo selenium sulfide external lotion 2.5 % silver sulfadiazine 1% cream Added QL QL: 400 GM/31 days SOVALDI 400 mg tablets stannous fluoride 0.63% rinse SUBOXONE sublingual film 2 mg-0.5 mg 8 mg-2 mg 4 mg-1 mg sulfacetamide sodium 10% ophthalmic ointment sulfacetamide sodium w/ sulfur emulsion all strengths suspenion 10-5% cleansing pad 10-4% PA QL: 28 tablets/28 days ZUBSOLV sublingual tablets 1.4 mg-0.36 mg 5.7 mg-1.4 mg sulfacetamide sodium ophthalmic solution 10 % sulfacetamide sodium external suspension 10 % SC022513_CAD_LTR_ENG State Approved 09112013 WellCare 2013 SC_04_13 52715

sumatriptan nasal spray - all strengths Updated QL QL: 12 ml /28 days sumatriptan solution for injection - all strengths Updated QL QL: 4 ml /28 days SYNAGIS solution for injection 100 mg/ml 50 mg/0.5 ml Updated PA TARGRETIN 1% gel TAZORAC cream, gel - all strengths QL: 30 GM/31 days AL: Max 20 YOA tobramycin/dexamethasone 0.3%-0.1% ophthalmic suspension tobramycin ophthalmic solution 0.3 % TOBREX 0.3% ophthalmic ointment tolmetin sodium 400 mg capsules tolnaftate 1% cream, powder tretinoin cream, gel - all strengths Added QL QL: 45 GM/31 days triamcinolone lotion 0.025% 0.1% triamcinolone acetonide external ointment cream 0.025 %, 0.1 %, 0.5 % 0.025% 0.5% tropicamide ophthalmic solution - all strengths ULORIC tablets all strengths allopurinol tablet UREA 40% lotion UREA cream VASOCLEAR A ophthalmic solution venlafaxine 75 mg extended-release capsules Removed ST QL: 31 capsules/31 days venlafaxine 150 mg extended-release capsules Added QL QL: 31 capsules/31 days VISINE 0.05% ophthalmic solution VISINE A.C. ophthalmic solution cromolyn sodium solution

VOLTAREN 1% gel QL: 300 GM/31 days ZOVIRAX 5% cream ZUBSOLV sublingal tablets 1.4 mg-0.36 mg 5.7 mg-1.4 mg PA ST: T/F oral acyclovir or valacyclovir within the past 100 days Generic Drugs italics BRAND DRUGS CAPS PDL Preferred Drug List PA Prior Authorization QL Quantity Limited ST Step Therapy SC022513_CAD_LTR_ENG State Approved 09112013 WellCare 2013 SC_04_13 52715