July 13, 2015 UPDATE WellCare s South Carolina Preferred Drug List 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 South Carolina Medicaid Preferred Drug List (), effective August 15, 2015. 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: 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 aminophylline 25 mg/ml solution amphetaminedextroamphetamine extended-release - all apap 325 mg argyle sterile 0.9% irrigation saline solution aspirin 81 mg enteric coated bismuth subsalicylate 262 mg/15 ml suspension ADDITIONS TO THE Analgesics - Added to the Nonnarcotic Antiasthmatic And Bronchodilator Added to the Agents ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Analgesics - Nonnarcotic Genitourinary Agents - Miscellaneous Analgesics - Nonnarcotic Antidiarrheals Page 1 of 19 Added to the w/ QL (62 /31 days) & AL: Min 6 YOA, Max 20 YOA Added to the Added to the Added to the Added to the calcium Added to the Alternative (if applicable)
carbonate/vitamin d 600 mg-400 unit Drug Name Therapeutic Class Change/Reason for Change clozapine 12.5 mg orally disintegrating delsym night time cough/cold 12.5-5 mg/5 ml liquid delsym night time cough/cold 6.25-2.5 mg/5 ml liquid DILANTIN 30 mg duloxetine 20 mg, 60 mg duloxetine 30 mg fentanyl 37.5 mcg, 62.5 mcg, 87.5 mcg patches IN-CHECK dial flow trainer device KALYDECO 50 mg, 75 mg granules lidocaine-prilocaine 2.5-2.5% kit Antipsychotics/Anti manic Agents Cough/Cold/Allergy Cough/Cold/Allergy Anticonvulsants Antidepressants Antidepressants Analgesics - Opioid Medical Devices Respiratory Agents - Misc. Added to the w/ QL (31 /31 days) & AL: Min 18 YOA Added to the Added to the Added to the w/ QL: 310 /31 days Added to the w/ QL (62 /31 days) & ST (trial of preferred SSRI, gabapentin, amitriptyline, or venlafaxine). Added to the w/ QL (31 /31 days) & ST (trial of preferred SSRI, gabapentin, amitriptyline, or venlafaxine). Added to the w/ PA & QL (10 patches/30 days) Added to the Added to the w/ PA Added to the lithium carbonate Antipsychotics/Anti Added to the Alternative (if applicable) Page 2 of 19
150 mg, 600 mg manic Agents Drug Name Therapeutic Class Change/Reason for Change melatonin maximum strength 5 mg methylphenidate hydrochloride chewable - all morphine sulfate preservative free 2 mg/ml, 4 mg/ml injection multivitamin/fluoride 0.25 mg chewable naproxen enteric coated 500 mg norethindrone & ethinyl estradiol-fe 0.8 mg-25 mcg chewable ONCASPAR 750 mg/ml injection oticin 1-0.1% otic liquid oyster shell calcium/d 250 mg- 125 unit phenytoin 50 mg chewable prenatal low iron 27-0.8 mg risperidone - all Alternative Medicines ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Analgesics - Opioid Analgesics - Anti- Inflammatory Contraceptives Otic Agents Anticonvulsants Antipsychotics/Anti manic Agents Added to the Added to the w/ AL: Min 6 YOA Added to the Added to the Added to the Added to the Added to the w/ PA Added to the Added to the Added to the w/ QL: 372 /31 days Added to the Added to the w/ QL (62 /31 days) & AL: Min 5 YOA Drug Name Therapeutic Class Change/Reason for Change Alternative (if applicable) Alternative (if applicable) Page 3 of 19
rizatriptan 5 mg, 10 mg SANTYL 250 unit/gm ointment slow release iron 160 (50 fe) mg extended-release tamoxifen 10 mg Migraine Products Hematopoietic Agents Page 4 of 19 Added to the w/ AL: Min 6 YOA, Max 17 YOA Added to the Added to the Added to the trinate Added to the vitamin b complex-c Added to the ZUBSOLV 8.6 mg- Added to the 2.1 mg sublingual Analgesics - Opioid w/ PA UTILIZATION MANAGEMENT CHANGES ALKERAN 2 mg butalbital-asacaffeine oral capsule 50-325-40 mg citalopram - all dextroamphetamine extended-release - all EMCYT 140 mg enoxaparin sodium injections - all Analgesics - Nonnarcotic Antidepressants ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Anticoagulants Added PA Removed QL Removed QL Updated QL: 31 /31 days 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: 12.4 ml/31 days 60 mg/0.6 ml: QL: 18.6 ml/31 days Drug Name Therapeutic Class Change/Reason for Change etoposide 50 mg GABITRIL 12 mg, 16 mg INVEGA SUSTENNA injection LEUKERAN 2 mg LOMUSTINE - all loxapine 5 mg LYSODREN 500 mg methylphenidate 10 mg extendedrelease methylphenidate - all MYLERAN 2 mg Anticonvulsants Antipsychotics/Anti manic Agents Antipsychotics/Anti manic Agents ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Page 5 of 19 Added PA Removed AL Updated QL : 117 mg/0.75 ml: QL: 0.75 ml/28 days 156 mg/ml: QL: 1 ml/28 days 234 mg/1.5 ml: QL: 1.5 ml/28 days 39 mg/0.25 ml: QL: 0.25 ml/28 days 78 mg/0.5 ml: QL: 0.5 ml/28 days Added PA Added PA Added AL: Min 18 YOA Added PA Added AL Max: Max 20 YOA Remove AL Max Added PA Alternative (if applicable)
nicotine polacrilex 2 mg, 4 mg mint gum Psychotherapeutic And Neurological Agents - Misc. Updated QL: 2016 pieces/365 days Drug Name Therapeutic Class Change/Reason for Change oxcarbazepine 600 mg PEG-3350 ELECTROL 236 gm, 240 gm solution risperidone 1 mg/ml solution SAPHRIS 5 mg, 10 mg sublingual spinosad 0.9% topical suspension sumatriptan succinate 6 mg/0.5 ml solution for injection TABLOID 40 mg thioridazine 100 mg ACETAMIN 80 mg/0.8 ml infant drops acetasol hydrocortisone 2-1% otic solution ACIDOPHILUS PROBIOTIC ACIDOPHILUS wafer Anticonvulsants Antipsychotics/Anti manic Agents Antipsychotics/Anti manic agents Migraine Products Antipsychotics/Anti manic Agents Removed QL QL added: 4,000 ml/31 days Updated QL & Added AL: QL:496 ml/31 days, AL: Min 5 YOA Updated AL: Min 10 YOA Updated AL: Min 6 months of age Updated QL: 4 injections/31 days Added PA Added AL: Min 2 YOA REMOVALS FROM THE Analgesics - Nonnarcotic Otic Agents Alternative (if applicable) Page 6 of 19
ACIDOPHILUS/BIFI DUS wafer Acidophilus/Pectin acitretin 17.5 mg acne wash 2 % liquid ADDERALL XR - all ADRUCIL 500 mg/10ml injection AFRIN 0.05% nasal spray solution ALTARYL 12.5 mg/5 ml syrup AMITIZA 8 mcg, 24 mcg antifungal 1 % aerosol artificial tears 83-15 % ophthalmic ointment artificial tears 0.1-0.3 % ophthalmic solution ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Nasal Agents - Systemic And Topical Antihistamines Gastrointestinal Agents - Misc. b complex 50 baby d-drops 400 unit/0.03 ml liquid amphetamine/dex troamphetamine extended-release - all (QL, AL may apply) fluorouracil 500 mg/10ml solution lactulose oral solution; polyethylene glycol Page 7 of 19
benzoyl peroxide 10%, 5% liquid wash benzoyl peroxide 6 % cleanser lotion beta care cream, lotion BP 10-1% emulsion BP 2.5 % liquid wash BP 4 % cleansing lotion calamine 8-8 % lotion calamine lotion calamine phenolated lotion calcitrate 315-250 mg-unit calcitriol 3 mcg/gm ointment calcium 1200-1200- 1000 mg-unit chewable calcium 500 + d 500-125 mg-unit calcium 600 + minerals 600-200 mg-unit calcium 600+d 600-200 mg-unit calcium 600+d plus minerals 600-400 mg-unit chewable Page 8 of 19
calcium 600+d plus minerals 600-400 mg-unit calcium 600-1500 mg calcium citrate 200 mg calcium-carbonate 600 + d 600-125 mg-unit calcium-magnesiumzinc 333-133-5 mg calcium-vitamin d 600-200 mg-unit cetaphil liquid chewable calcium 500-200-40 mg-untmcg chewable children's complete allergy 12.5 mg chewable childrens silfedrine 15 mg/5ml liquid citranatal dha 27-1 & 250 mg pak Antihistamines Nasal Agents - Systemic And Topical citranatal rx 27-1 mg clemastine fumarate 0.67 mg/5 ml syrup Antihistamines colloidal oatmeal bath packet complete natal dha 29-1-200 & 250 mg pak Page 9 of 19
condoms Medical Devices COPEGUS 200 mg Service for CORDRAN 4 mcg/sqcm tape dermaphor ointment dexamethasone sodium phosphate preservative free 10 mg/ml injection Corticosteroids dexamethasone sodium phosphate injection solution 10 mg/ml DIFF-STAT chewables diltiazem hydrochloride 100 mg reconstituted solution intravenous Calcium Channel Blockers diltiazem hcl intravenous solution 125 mg/25ml, 25 mg/5ml, 50 mg/10ml diphenhydramine 12.5 mg/5 ml elixir Antihistamines domeboro packet doxycycline monohydrate 100 mg Tetracyclines doxycycline monohydrate 100 mg ENDOMETRIN 100 mg suppositories Vaginal Products progesterone 100 mg etoposide 500 mg/25 ml injection EURAX 10% cream, lotion permethrin external lotion 1 %; permethrin Page 10 of 19
external cream 5 % exemestane 25 mg eye drops advanced relief 0.05-0.1-1-1 % ophthalmic solution fareston 60 mg anastrozole oral tablet tamoxifen 10 mg FIBER THERAPY 500 mg FLORANEX chewables flutamide 125 mg FORMULA EM 1.87-1.87-21.5 solution Antiemetics GAVILYTE-C SOL 60/15 ml stool softener syrup GENERESS FE chewable Contraceptives norethindrone & ethinyl estradiolfe 0.8 mg-25 mcg chewable genteal 0.25-0.3 % ophthalmic gel genteal mild 0.2 % ophthalmic solution genteal mild to moderate 0.3 % ophthalmic solution genteal severe 0.3 % ophthalmic gel glycerin 2 gm, 2.1 gm suppositories Page 11 of 19
glycerin liquid GNP capsaicin 0.1 % cream goniovisc 2.5 % ophthalmic solution haloperidol 20 mg HARVONI 90-400 mg hemorrhoidal 0.25-3-14-71.9 % ointment hemorrhoidal 0.25-3-85.5 % suppository homatropine hydrobromide 5 % ophthalmic solution hydrocortisone-aloe 0.5%, 1% cream INCIVEK 375 mg INFERGEN injections - all INSPIREASE bags, mouthpiece Antipsychotics/Anti manic Agents Anorectal Agents Anorectal Agents Medical Devices haloperidol oral tablet 10 mg Service for atropine sulfate ophthalmic solution Service for Service for Page 12 of 19
invisible acne treatment 10 % cream KALA KLOR-CON 20 meq, 25 meq packets lactobacillus, packets, wafers LAXATIVE W/SENNA 25 mg leuprolide 1 mg/0.2 ml injection LICE KILLING maximum strength 0.33-4% shampoo lice treatment 0.33-4 % liquid lice treatment 1 % liquid loperamidesimethicone 2-125 mg lubricant eye drops 0.4-0.3 % ophthalmic solution lubricating plus eye drops 0.5 % ophthalmic solution LUPRON-DEPOT injection - all magnesium citrate 1.745 gm/30ml solution Antidiarrheals Antidiarrheals Page 13 of 19 KLOR-CON oral ; potassium chloride oral solution 20meq/15ml (10%) spinosad 0.9% topical suspension spinosad 0.9% topical suspension spinosad 0.9% topical suspension TRELSTAR suspension
methyldopate hydrochloride 250 mg/5 ml solution METHYLIN chewable - all metronidazole 0.75 % gel MINERAL OIL ENEMA MODERIBA pak - all muscle relief 0.075 % cream naproxen sodium 220 mg nasal decongestant 10 mg natures tears 0.4 % ophthalmic solution NATURL FIBER 68% powder NIACIN er 250 mg extended-release NORDITROPIN flexpro solution - all OLYSIO 150 mg Antihypertensives ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants Analgesics - Anti- Inflammatory Nasal Agents - Systemic And Topical Endocrine And Metabolic Agents - Misc. Page 14 of 19 methylphenidate hcl chewable tabs - all (AL may apply) metronidazole external 1 % Service for naproxen oral tablet 250 mg, 375 mg, 500 mg no flush niacin oral tablet 500 mg OMNITROPE subcutaneous solution (PA applies) Service for
ORAL SALINE laxative solution oyst-cal d 250-125 mg-unit oyster shell calcium +D 500 mg-400u oyster shell calcium 250+d 250-125 mgunit oyster shell calcium/d 500-200 mgunit PAIN & FEVER 80 mg chewables Analgesics - Nonnarcotic parva-cal 500-200 mg-unit PEDIA-LAX 1 gm suppositories PEGASYS kit, injection, proclick PEG-INTRON kit - all phenazo 95 mg polyvitamin/iron chewable potassium bicarbonate 25 meq effervescent Genitourinary Agents - Miscellaneous Service for Service for phenazopyridine hcl oral tablet 100 mg, 200 mg potassium chloride crys er oral tablet extendedrelease 10 meq, 20 meq Page 15 of 19
potassium citrate 5 meq (540 mg) extended-release Genitourinary Agents - Miscellaneous cytra-2 oral solution pr natal 400 29-1- 200 & 400 mg pak pr natal 430 29-1- 200 & 430 mg pak pr natal 430 ec 29-1-200 & 430 mg (dr) pak PROBIOTIC DAILY promethazine 25 mg/ml injection promethazine hydrochloride 50 mg/ml solution injection PROMETHEGAN SUPPOSITORY 12.5 MG PSYLDEX 30% powder pyrethins-piperonyl butoxide 0.2-2 % liquid QC NATURAL VEGETABLE powder RA aspirin 500 mg Antihistamines Antihistamines Antihistamines Analgesics - Nonnarcotic promethazine hcl suppository 25 mg RA COL-RITE 50MG ra hemorrhoidal 0.25-3-12-18 % cream REBETOL 40 mg/ml solution 200 mg Anorectal Agents Page 16 of 19
REBETRON kit - all REGONOL 5 mg/ml injection Antimyasthenic/Chol inergic Agents Service for Service for renal 1 mg ribavirin 500 mg salivasure mouth/throat lozenges SB FIB LAX 33% powder sb lice treatment 0.3-3 % liquid select-ob 29-1 mg chewable Mouth/Throat/Dental Agents Service for spinosad 0.9% topical suspension sf 5000 plus 1.1 % dental cream sirolimus 1 mg, 2 mg sm ibuprofen 100 mg junior, chewables SMOOTH LAX 3350 NF powder packets Mouth/Throat/Dental Agents Assorted Classes Analgesics - Anti- Inflammatory PHOS-FLUR DENTAL 1.1 % tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg Page 17 of 19
sodium chloride (hypertonic) 5% ophthalmic solution SOVALDI 400 mg SUDAFED-12 12 hr* 120 mg extended-release sulfacetamide sodium- sulfur 10-5% cream, lotion tears again ophthalmic ointment tolnaftate 1 % solution TUCKS 51% suppository UNIVERT 32 mg verapamil hydrochloride 2.5 mg/ml solution injection VICTRELIS 200 mg VIEKIRA pak vitamin a 10,000 unit Nasal Agents - Systemic And Topical Anorectal Agents Antiemetics Calcium Channel Blockers Page 18 of 19 Service for sulfacetamide sodium external suspension 10 % Service for Service for
vitamin a 25,000 unit vitamin a palmitate 15,000 unit vitamin c 500 mg extended-release vitamin c 500 mg/5ml liquid vitamin c tablet 1000 MG ORAL; vitamin c tablet 100 MG vitamin D 400 unit vitamin d3 2,000 unit super strength vitamin d3 50,000 unit vitatrum chewable zinc 25 mg ZYTIGA 250 mg If you have questions, WellCare s Pharmacy Help Desk and its affiliated vendor, Catamaran, are available to assist providers at 1-888-588-9842. Thank you for your care of WellCare s South Carolina Medicaid members. Sincerely, WellCare Health Plans, Inc. Page 19 of 19