update healthease kids/staywell kids medicaid … decided that the following changes will be made to...

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FL028175_PRO_LTR_ENG Internal Approved 11242014 63586 © WellCare 2014 FL_11_14

January 06, 2015 Dear Provider: At the December 11, 2014 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the Staywell Kids and HealthEase Kids Healthy Kids Preferred Drug List (PDL), effective February 11, 2015. Please carefully review these changes.

Key UPPER CASE = Brand Name Drugs QL = Quantity Limit Lower case italics = Generic Drugs ST = Step Therapy PDL = Preferred Drug List AL = Age Limit PA = Prior Authorization YOA = Years of Age

Effective date of change: February 11, 2015

Drug Name Therapeutic Class Change PDL Alternative

(if applicable) ADDITIONS TO THE PDL

fish oil 1000 mg capsules

Nutrients; Misc. Nutritional Substances

Added to the PDL

HUMIRA 10 mg/0.2 mL injection

Analgesics - Anti-Inflammatory; Anti-TNF-alpha - Monoclonal Antibodies

Added to the PDL w/ PA

INVOKAMET tablets - all strengths

Antidiabetics; Antidiabetic Combinations; Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb

Added to the PDL w/ Step (Must t/f metformin, metformin er, or riomet within the past 100 days)

INVOKANA tablets - all strengths

Antidiabetics; Sodium-Glucose

Added to the PDL w/ Step (Must t/f

UPDATE HealthEase Kids/Staywell Kids Medicaid

Preferred Drug List

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Co-Transporter 2 Inhibitors

metformin, metformin er, or riomet within the past 100 days)

ivermectin 3 mg tablets Anthelmintics

Added to the PDL w/ QL (10 tablets/31 days)

JARDIANCE tablets - all strengths

Antidiabetics; Sodium-Glucose Co-Transporter 2 Inhibitors

Added to the PDL w/ Step (Must t/f metformin, metformin er, or riomet within the past 100 days)

lactated ringers injection

Minerals & Electrolytes; Electrolytes Mixtures; Electrolytes Parenteral

Added to the PDL

mag-sr 535 mg tablets Minerals & Electrolytes; Magnesium

Added to the PDL

mag-tab 84 mg sustained-release tablets

Minerals & Electrolytes; Magnesium

Added to the PDL

oyster shell 500 mg tablets

Minerals & Electrolytes; Calcium

Added to the PDL

phospha 250 neutral tablets

Minerals & Electrolytes; Phosphate

Added to the PDL

potassium chloride extended-release capsules • 8 meq • 10 meq • 20 meq

Minerals & Electrolytes; Potassium

Added to the PDL

potassium chloride/sodium

Minerals & Electrolytes;

Added to the PDL

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chloride 0.15-0.9% injection

Electrolytes Mixtures; Electrolytes Parenteral

sodium chloride tablets • 1 GM solution for injection • 0.45%

Minerals & Electrolytes; Sodium

Added to the PDL

TYBOST 150 mg tablets

Antivirals; Antiretrovirals Adjuvants

Added to the PDL w/ QL (31 tablets/31 days)

vitamin C 500 mg tablets

Vitamins; Water Soluble Vitamins; Vitamin C

Added to the PDL

vitamin D3 capsules • 400 unit • 1000 unit • 2000 unit

Vitamins; Oil Soluble Vitamins; Vitamin D

Added to the PDL

vitamin E 400 unit capsules

Vitamins; Oil Soluble Vitamins; Vitamin E

Added to the PDL

zinc sulfate 220 mg capsules

Minerals & Electrolytes; Zinc Added to the PDL

REMOVALS FROM THE PDL

STROMECTOL 3 mg tablets Anthelmintics Removed from

PDL

ivermectin 3 mg tablets (QL: 10 tablets/31 days)

If you have questions, our Pharmacy Help Desk and its affiliated vendor, Catamaran Rx, are available to help you at 1-866-698-5437. Thank you for your care of Staywell Kids and HealthEase Kids Medicaid members. Sincerely, Staywell Kids and Health Ease Kids

update healthease kids/staywell kids medicaid … decided that the following changes will be made to...

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