March 26, 2015 UPDATE Georgia Medicaid 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 Health Plan Georgia Medicaid Preferred Drug List (PDL), effective May 15, 2015. 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: May 15, 2015 Key QL = Quantity Limit ST = Step Therapy AL = Age Limit YOA = Years of Age Drug Name Therapeutic Class Change acyclovir 5% ointment BENICAR - all strengths ADDITIONS TO THE PDL Dermatologicals; Antivirals - Topical Antihypertensives;A ngiotensin II Receptor Antagonists w/ ST (Trial of preferred oral acyclovir or valacyclovir within the past 100 days). w/ ST (Trial of losartan and valsartan). PDL Alternative (if colchicine 0.6 mg Gout Agents desogestrel/ethinyl estradiol doxycycline monohydrate 50 mg, Tetracyclines Page 1 of 6
100 mg capsules Drug Name Therapeutic Class Change/Reason drospirenone/ethinyl estradiol 3.0 mg-0.03 mg DROXIA capsules - all strengths Agents; Agents For Sickle Cell Anemia;Cytotoxic Agents ferrous fumarate 325 mg Agents;Iron ferrous sulfate 220 mg/5 ml liquid HARVONI 90 mg - 400 mg insupen mis 33Gx4mm lamivudine 10 mg/ml oral solution levonorgestrel/ethinyl estradiol 0.1 mg-0.02 mg methylprednisolone 4 mg mycophenolate mofetil 200 mg/ml oral suspension Agents;Iron Antivirals;Hepatitis C Agent - s Medical Devices; Parenteral Therapy Supplies; Needles & Syringes Antivirals; Antiretrovirals - RTI- Nucleoside Analogues- Pyrimidines Corticosteroids; Glucocorticosteroids Assorted Classes; Immunosuppresive Agents; Inosine Monophosphate Dehydrogenase Inhibitors w/ PA and QL (28 /28 days) Page 2 of 6
Drug Name Therapeutic Class Change/Reason norgestimate/ethinyl estradiol norgestimate/ethinyl estradiol 0.25 mg-0.35 mg OMNITROPE 5.8 mg polysaccharide iron 150 mg capsules prednisone 50 mg paks 5 mg 10 mg progesterone 100 mg capsules propranolol oral solution - all strengths quinidine sulfate 200 mg VALSARTAN - all strengths vitamin B-12 500 mcg time-release 1,000 mcg sublingual Endocrine and Metabolic Agents - Misc.; Growth Hormones Agents;Iron Corticosteroids; Glucocorticosteroids Progestins Beta Blockers; Beta Blockers Non- Selective Type I-A Antihypertensives;A ngiotensin II Receptor Antagonists Agents;Cobalamins w/ PA w/ ST (Trial of losartan). Page 3 of 6
1,000 mcg Drug Name Therapeutic Class Change/Reason VYVANSE 10 mg capsules ADHD/Anti- Narcolepsy/Anti- Obesity/Anorexiants; Amphetamines w/ QL: 31 /31 days and AL: Min 6 YOA, Max 20 YOA XULANE transdermal patch Transdermal doxycycline hyclate 100 mg capsules 50 mg 100 mg UTILIZATION MANAGEMENT CHANGES Added ST: Trial of preferred doxycycline Tetracyclines monohydrate capsules within the past 100 days). REMOVALS FROM THE PDL amiodarone 150 mg/ml 50 mg/ml Type III calcitriol 1 mcg/ml Endocrine and Metabolic Agents - Misc.; Metabolic Modifiers; Hyperparathyroid Treatment - Vitamin D Analogs CELLCEPT 200 mg/ml oral suspension Assorted Classes; Immunosuppressive Agents; Inosine Monophosphate Dehydrogenase Inhibitors mycophenolate mofetil 200 mg/ml oral suspension EPIVIR 10 mg/ml oral solution Antivirals;Antiretrovir als-rti-nucleoside Analogues- Pyrimidines lamivudine 10 mg/ml oral solution Page 4 of 6
Drug Name Therapeutic Class Change/Reason levothyroxine 100 mcg NATURE-THROID 113.75 mg 146.25 mg 325 mg ARMOUR THYROID procainamide 100 mg/ml 500 mg/ml Type I-A propranolol hydrochloride/hydrochl orothiazide - all strengths Antihypertensives; Antihypertensives s; Beta Blocker & Diuretic s propranolol hcl + hydrochlorothiazide quinidine gluconate 80 mg/ml Type I-A SAVELLA titration pak, - all strengths Pyschotherapeutic and Neurological Agents - Misc.; Fibromyalgia Agent - SNRIs gabapentin, capsules (QL may apply) TEV-TROPIN 5 mg Endocrine and Metabolic Agents - Misc.; Growth Hormones OMNITROPE 5.8 mg THYROLAR - all strengths levothyroxine ; liothyroxine WESTHROID - all strengths ARMOUR THYROID If you have questions, WellCare Health Plan s Pharmacy Help Desk and its affiliated vendor, Catamaran Rx, are available to assist providers at 1-866-231-1821. Page 5 of 6
Thank you for your care of WellCare Medicaid members. Sincerely, WellCare Health Plans, Inc. Page 6 of 6