UPDATE Ohana QUEST Integration Medicaid Preferred Drug List June 29, 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 Ohana QUEST Integration 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 SC = Safety Concerns PC = Pharmacoeconomic Considerations GA = Generic Available Effective date of change: August 15, 2015 Key QL = Quantity Limit ST = Step Therapy AL = Age Limit YOA = Years of Age LU = Low Utilization DD = Discontinued Drug ADDITIONS TO THE alprazolam 1 mg/ml concentrate Antianxiety Added to the amphetaminedextroamphetamine w/ QL (62 caps/31 Added to the Narcolepsy/Antiextended-release days) & AL: Min 6 - YOA, Max 20 YOA apap 325 mg Analgesics - Added to the ascorbic acid 500 mg Vitamins Added to the bicalutamide 50 mg dexmethylphenidate hydrochloride 10 mg sustained-release diphenhydramine 50 mg duloxetine - EVOTAZ 150 mg - 300 mg Antihistamines Antidepressants Antivirals Added to the Added to the Added to the Added to the Added to the Alternative (if ) Page 1 of 6
kit KALYDECO 50 mg, 75 mg granules lamivudine 10 mg/ml solution lamotrigine 100 mg, 200 mg orally disintegrating lamotrigine 25 mg, 50 mg orally disintegrating methylphenidate hydrochloride chewable - all strengths norethindrone & ethinyl estradiol-fe 0.8 mg-25 mcg chewable ONCASPAR 750 mg/ml injection PREZCOBIX 800 mg - 150 mg PRISTIQ 25 mg rizatriptan 5 mg, 10 mg UNITHROID 137 mcg vitamin C 500 mg ZUBSOLV 8.6 mg-2.1 mg sublingual atovaquone 750 mg/5 ml suspension enoxaparin sodium injections - Inflammatory Respiratory - Misc. Antivirals Anticonvulsants Anticonvulsants Added to the fentanyl 37.5 mcg, 62.5 Analgesics - Opioid & QL (10 mcg, 87.5 mcg patches patches/30 days) HUMIRA psoriasis pen Analgesics - Anti- Added to the Contraceptives Antivirals Antidepressants Migraine Products Thyroid Vitamins Analgesics - Opioid Added to the Added to the Added to the Added to the w/ QL (310 tabs /31 days) Added to the Added to the Added to the Added to the Added to the w/ ST (Trial/fail 2 generic antidepressants) Added to the w/ AL: Min 6 YOA, Max 17 YOA Added to the Added to the Added to the UTILIZATION MANAGEMENT CHANGES Anti-Infective - Misc. Anticoagulants Added PA Updated QL: 300 MG/3 ML: QL: 93 100 MG/ML: QL: 31 150 MG/ML: QL: 31 120 MG/0.8 ML: QL: 24.8 80 MG/0.8 ML: QL: 24.8 Alternative (if Page 2 of 6
nicotine polacrilex 2 mg, 4 mg mint lozenges spinosad 0.9% topical suspension Dermatologicals Page 3 of 6 30 MG/0.3 ML: QL: 9.3 40 MG/0.4 ML: QL: 12.4 60 MG/0.6 ML: QL: 18.6 Updated QL: 620 lozenges/31 days Updated AL: Min 6 months of age REMOVALS FROM THE ace aerosol cloud enhancer Medical Devices ADDERALL XR - ADRUCIL 500 mg/10ml injection artificial tears 83-15 % ophthalmic ointment Ophthalmic b complete b complex balanced b-50 complex b-complex formula 1 better b complex, BRISDELLE 7.5 mg brotapp 1-15 mg/5ml liquid buproban 150 mg Cough/Cold/Allergy Alternative (if amphetamine - dextroamphetamine extended-release caps - (QL & AL apply) fluorouracil 500 mg/10ml solution paroxetine hcl er oral tablet extended release 24hr bupropion 150 mg SR 12HR c-500 500 mg Vitamins chewable calcitrate 315-250 mgunit calcium citrate + d 315-200 mg-unit Alternative (if centavite a-z complete-
flurazepam - FOCALIN XR 10 mg GENERESS FE chewable glycerin 1.2 GM, 2.1 GM suppositories hypotears 1-1 % ophthalmic solution ibuprofen 100 mg junior chewables LAMICTAL orally disintegrating - magnesium 250 mg magnesium citrate 1.745 gm/30ml solution mapap 500 mg METHYLIN chewable - Nasal - Systemic And Topical Cough/Cold/Allergy Otic Vaginal Products Hypnotics/Sedatives/ Sleep Disorder mineral certavite/antioxidants liquid childrens silfedrine 15 mg/5ml liquid cold & allergy 1-2.5 mg/5ml elixir earwax treatment 6.5 % otic solution ENDOMETRIN 100 mg suppositories ERWINAZE 10,000U injection fe c plus 100-250- 0.025-1 mg ferrous gluconate 324 (38 fe) mg Contraceptives Ophthalmic Analgesics - Anti- Inflammatory Anticonvulsants Analgesics - Page 4 of 6 progesterone 100mg capsule temazepam - all strengths dexmethylphenidate hcl 10 mg sustainedrelease (QL & AL apply) norethindrone & ethinyl estradiol-fe 0.8 mg-25 mcg chewable lamotrigine 25 mg, 50 mg orally disintegrating (QL) methylphenidate hcl chewable - all strengths (QL & AL apply) Alternative (if MILK of magnesia 400 mg/5 ml suspension MONISTAT-1 1200 Vaginal Products
mg-2% combo pack kit multigen 70 mg naproxen 500 mg delayed-release nasal decongestant 30 mg/5ml liquid natural fiber therapy 30.9 % powder Analgesics - Anti- Inflammatory Nasal - Systemic And Topical Page 5 of 6 nephronex nicotrol 10 mg inhaler, 0.5mg/actuation nasal spray nortemp infant 80 mg/0.8 ml suspension optics eye wash 0.9 % ophthalmic solution oyst-cal d 250-125 mg-unit oyster shell calcium +D 500 mg-400u oyster shell calcium/d 500-200 mgunit preparation-h 50% pads promethazine 25 mg/ml injection Analgesics - Ophthalmic Dermatologicals Antihistamines renal 1 mg SAVELLA - all strengths stress formula/zinc SUDAFED-12 12 hr* Nasal - 120 mg extendedrelease Systemic And Topical super b-50 b complex capsule tears again ophthalmic ointment Ophthalmic tri-buff asa 325 mg Analgesics - vitamin b-12 1,000 mcg extended-release naproxen 250 mg, 375 mg, 500 mg nicotine transdermal patch 24 hr 14 mg/24hr, 21 mg/24hr, 7 mg/24hr promethazine hcl 25 mg suppository; promethazine hcl 12.5 mg, 25 mg, 50 mg gabapentin; duloxetine - Alternative (if
vitamin b-12 250 mcg 500 mcg sublingual 1000 mcg vitamin c 100 mg 1,000 mg extended-release 1000-100 mg vitamins for hair If you have questions, Ohana Health Plan s Pharmacy Help Desk and its affiliated vendor, Catamaran Rx, are available to assist providers at 1-888-846-4262. Thank you for your care of Ohana Medicaid members. Sincerely, Ohana Health Plan Pharmacy Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. Page 6 of 6