WellCare s 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 09/21/2017. Please look at these changes. Call WellCare s 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. They are happy to help. Date of Change: 12/05/2017 DRUG NAME DESCRIPTION OF CHANGE REASON FOR CHANGE Requirements/Limits/Alternatives ABILIFY MAINTENA 300 mg, 400 mg extended-release powder for suspension for w/ PA & QL PA & QL: 1 vial / 28 days BEXSERO suspension for w/ AL & QL: AL & QL: Members 18 YOA & Younger: patient age 19 years Members 19 to 25 YOA: Covered: QL: 1 ml (2 doses) / per lifetime Members 26 YOA & Older: Plan limitations exceeded; Maximum patient age of 25 years CHANTIX STARTING MONTH PAK 0.5 mg X 11 & 1 mg X 42 tablet w/ QL QL: 53 tablets / 365 days
CHANTIX 0.5 mg, 1 mg tablet w/ QL QL: 112 tablets / 365 days CHANTIX CONTINUING MONTH PAK 1 mg tablet w/ QL QL: 112 tablets / 365 days clindamycin 1 % pad w/ QL QL: 60 pads / 30 days clobetasol propionate 0.05 % solution desonide 0.05 % ointment diazepam 5 mg/ml for solution Removed from the PDL diazepam oral and rectal gel flutamide 125 mg capsule hydrocortisone 0.5 % cream INVEGA SUSTENNA 117 mg/0.75 ml suspension for INVEGA SUSTENNA 156 mg/ml suspension for INVEGA SUSTENNA 234 mg/1.5 ml suspension for INVEGA SUSTENNA 39 mg/0.25 ml suspension for w/ PA & QL PA & QL: 0.75 ml / 28 day w/ PA & QL PA & QL: 1 ml / 28 days w/ PA & QL PA & QL: 1.5 ml / 28 days w/ PA & QL PA & QL: 0.25 ml / 28 days INVEGA SUSTENNA 78 w/ PA & QL PA & QL: 0.5 ml / 28 days mg/0.5 ml suspension for
INVEGA TRINZ 273/0.875 ml suspension for INVEGA TRINZ 410/1.315 ml suspension for INVEGA TRINZ 546/1.75 ml suspension for INVEGA TRINZ 819/2.625 ml suspension for w/ PA & QL PA & QL: 0.875 ml / 91 day w/ PA & QL PA & QL: 1.315 ml / 91 days w/ PA & QL PA & QL: 1.75 ml / 91 day w/ PA & QL PA & QL: 2.625 ml / 91 days leucovorin calcium 50 mg powder for methotrexate 25 mg/ml multidose vial for M-M-R II vaccine w/ AL & QL AL & QL: Members 19 YOA & Older: Covered; QL: 2 vials (2 doses) / 365 days Members 18 YOA & Younger: patient age of 19 years naproxen sodium 275 mg, 550 mg oral tablet Removed from the PDL naproxen oral tablet 250 mg, 375 mg, 500 mg NICOTROL 10 mg/ml nasal spray NICOTROL inhaler omega-3-acid ethyl esters 1
gram capsules SEREVENT DISKUS aerosol powder breath activated 50 mcg/dose inhalation Removed from the PDL FORADIL aerolizer kit 12 mcg powder for inhalation triamcinolone acetonide 0.5 % ointment TRUMENBA w/ AL & QL AL & QL: Members 18 YOA & younger: Not covered; Minimum patient age of 19 years Members 19 to 25 YOA Covered; QL: 1.5 ml (3 doses)/ per lifetime Members 26 YOA & older: Not covered: Maximum patient age of 25 years VARIVAX w/ AL & QL AL & QL: Members 18 YOA and younger: Not covered; Minimum patient age of 19 years Members 19 YOA and older: Covered; QL: 2 vials (2 doses) / 365 days ZEGERID 20-1100 mg capsule ZUBSOLV sublingual 0.7mg- 0.18 mg tablet Removed PA; Added AL & QL: Safety Concerns AL & QL:
ZUBSOLV sublingual 1.4mg- 0.36 mg tablet ZUBSOLV sublingual 11.4mg- 2.9 mg tablet Not covered Covered; QL : 31 tablets / 31 days ZUBSOLV sublingual 2.9mg- 0.71 mg tablet
ZUBSOLV sublingual 5.7mg- 1.4 mg tablet ZUBSOLV sublingual 8.6mg- 2.1 mg tablet Generic Drugs italics BRAND DRUGS CA PS PDL Preferred Drug List P A Prior Authorization Q L Quantity Limit ST Step Therapy A L Age Limit YO A Years of Age