March 26, 2015 UPDATE WellCare s South Carolina Preferred Drug List Dear Provider: At the March 05, 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 May 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: May 15, 2015 Key QL = Quantity Limit ST = Step Therapy AL = Age Limit YOA = Years of Age Drug Name Therapeutic Change Class ADDITIONS TO THE acyclovir 5% ointment Dermatologicals; Antivirals - Topical BENICAR - all strengths colchicine 0.6 mg desogestrel/ethinyl estradiol doxycycline hyclate 20 mg doxycycline monohydrate 50 mg, Antihypertensives; Angiotensin II Receptor Antagonists Gout Agents Tetracyclines Tetracyclines Page 1 of 9 Added to the w/ ST (Trial of preferred oral acyclovir or valacyclovir within the past 100 days). Added to the w/ ST (Trial of losartan and valsartan). Added to the Added to the Added to the Added to the Alternative (if
100 mg capsules drospirenone/ethinyl estradiol 3.0 mg-0.03 mg DROXIA capsules - all strengths ferrous fumarate 325 mg ferrous sulfate 220 mg/5 ml liquid glipizide-metformin hydrochloride 5-500 mg HARVONI 90 mg - 400 mg insupen mis 33Gx4mm lamivudine 10 mg/ml oral solution levonorgestrel/ethinyl estradiol 0.1 mg-0.02 mg Agents; Agents For Sickle Cell Anemia;Cytotoxic Agents Agents;Iron Agents;Iron Antidiabetics; Antidiabetics s; Sulfonylurea- Biguanide s Antivirals;Hepatitis C Agent - s Medical Devices; Parenteral Therapy Supplies; Needles & Syringes Antivirals; Antiretrovirals - RTI-Nucleoside Analogues- Pyrimidines Added to the Added to the Added to the Added to the Added to the Added to the w/ PA and QL (28 /28 days) Added to the Added to the Added to the Alternative (if LUMIZYME 50 mg Endrocrine and Added to the Page 2 of 9
w/ PA Misc.; Metabolic Modifiers; GAA Deficiency Treatment - Agents methylprednisolone - all strengths metoprolol tartate 25 mg mycophenolate mofetil 200 mg/ml oral suspension OMNITROPE 5.8 mg polysaccharide iron 150 mg capsules prednisone 5 mg, 10 mg paks progesterone 100 mg capsules propranolol oral solution - all strengths propranolol 1 mg/ml quinidine sulfate 200 mg Corticosteroids; Glucocorticosteroi ds Beta Blockers; Beta Blockers Cardio-Selective Assorted Classes; Immunosuppresive Agents; Inosine Monophosphate Dehydrogenase Inhibitors Misc.; Growth Hormones Agents;Iron Corticosteroids; Glucocorticosteroi ds Progestins Beta Blockers; Beta Blockers Non-Selective Beta Blockers; Beta Blockers Non-Selective Antiarrhythmics; Antiarrhythmics Type I-A Added to the Added to the Added to the Added to the w/ PA Added to the Added to the Added to the Added to the Added to the Added to the Alternative (if Page 3 of 9
sotalol af 120 mg torsemide 5 mg VALSARTAN - all strengths vitamin B-12 500 mcg sublingual 1,000 mcg VYVANSE 10 mg capsules alendronate 10 mg 40 mg 70 mg chateal 0.15 mg-30 mg doxycycline hyclate 100 mg capsules 50 mg 100 mg heather 0.35 mg Beta Blockers; Beta Blockers Non-Selective Diurectics; Loop Diurectics Antihypertensives; Angiotensin II Receptor Antagonists Agents;Cobalamin s ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiant s; Amphetamines Page 4 of 9 Added to the Added to the Added to the w/ ST (Trial of losartan). Added to the Added to the w/ QL: 31 /31 days and AL: Min 6 yrs, Max 20 YOA UTILIZATION MANAGEMENT CHANGES Misc.; Biphosphonates Tetracyclines Progestin Added ST (Trial of preferred doxycycline monohydrate capsules within the past 100 days). Alternative (if
norgestimate/ethinyl estradiol PLAN-B 1.5 mg XULANE transdermal patch alendronate 70 mg/75 ml solution amiodarone 150 mg/ml 50 mg/ml CELLCEPT 200 mg/ml oral suspension chlorothiazide 500 mg clopidogrel 300 mg COUMADIN - all strengths Emergency Contraceptives Transdermal Page 5 of 9 REMOVALS FROM THE Misc.; Biphosphonates Antiarrhythmics; Antiarrhythmics Type III Assorted Classes; Immunosuppressiv e Agents; Inosine Monophosphate Dehydrogenase Inhibitors Diurectics; Thiazides and Thiazide-Like Diurectics Hematological Agents - Misc.;Platelet Aggregation Inhibitors;Thienopy ridine Derivatives Anticoagulants; Coumarin Anticoagulants Alternative (if alendronate sodium oral tablet mycophenolate mofetil 200 mg/ml oral suspension Clopidogrel 75 mg warfarin
DE-CHLOR DM liquid digox 0.125 mg, 0.250 mg EPIVIR 10 mg/ml oral solution Cough/Cold/Allerg y;cough/cold/aller gy s; Non-Narc Antitussive- Decongestant- Antihistamine Cardiotonics; Cardiac Glycosides Antivirals;Antiretro virals-rti- Nucleoside Analogues- Pyrimidines Alternative (if digoxin oral tablet 0.125 mg, 0.250 mg lamivudine 10 mg/ml oral solution feosol 45 mg Agents;Iron ferrrous sulfate oral JUXTAPID capsules - all strengths Antihyperlipidemic s; Microsomal Triglyceride Transfer Protein (MTP) Inhibitors KORLYM 300 mg LANOXIN 0.125 mg 0.250 mg 0.25 mg/ml Antidiabetics; Diabetic Other; Progesterone Receptor Antagonists Cardiotonics; Cardiac Glycosides liothyronine 10 mcg/ml digoxin oral tablet 0.125 mg, 0.250 mg Alternative (if MESEHIST DM liquid Cough/Cold/Allerg y;cough/cold/aller Page 6 of 9
gy s; Non-Narc Antitussive- Decongestant- Antihistamine metformin 1,000 mg extended-release Antidiabetics; Biguanides metformin oral MOZOBIL 24 mg/1.2 ml solution for mycophenolic 180 mg delayed-release NATURE-THROID 113.75 mg 146.25 mg 325 mg NEORAL solution, capsules - all strengths niacin extendedrelease 750 mg 1,000 mg Agents; Stem Cell Mobilizers; CXCR4 Receptor Antagonist Assorted Classes; Immunosuppresive Agents; Inosine Monophosphate Dehydrogenase Inhibitors Assorted Classes; Immunosuppresive Agents; Cyclosporine Analogs Antihyperlipidemic s; Nicotinic Acid Derivatives Page 7 of 9 NORDITROPIN 30 mg/3 ml Endrocrine and Misc.; Growth Hormones prednisolone 25 Corticosteroids; mycophenolic oral tablet 500mg ARMOUR THYROID cyclosporine oral solution, capsules niacin oral, niacin ER oral capsule 500mg Alternative (if OMNITROPE (PA)
mg/5 ml solution Glucocorticosteroi ds propranolol hydrochloride/hydroc hlorothiazide - all strengths Antihypertensives; Antihypertensives s; Beta Blocker & Diuretic s propranolol hydrochloride + hydrochlorothiazide SAVELLA titration pak, - all strengths Pyschotherapeutic and Neurological Agents - Misc.; Fibromyalgia Agent - SNRIs gabapentin, capsules (QL may apply) SENSIPAR - all strengths Misc.; Metabolic Modifiers; Calcimimetic Agents SYNTHROID - all strengths levothyroxine sodium oral taron forte capsules Agents;Hematopoi etic Mixtures;Iron s poly-iron 150 forte oral capsule 150-25-1 mg-mcg-mg TEV-TROPIN 5 mg Misc.; Growth Hormones OMNITROPE (PA) THYROLAR - all strengths levothyroxine, liothyronine TRI-DEX PE liquid Cough/Cold/Allerg y;cough/cold/aller gy s; Non-Narc Antitussive- Decongestant- Antihistamine Alternative (if Page 8 of 9
VALCYTE 450 mg Antivirals; CMV Agents WESTHROID - all strengths ARMOUR THYROID 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 9 of 9