UPDATE

April 10, 2014

WellCare of South Carolina Preferred Drug List Dear Provider: At the February 27, 2014 WellCare Pharmacy & Therapeutics Committee meeting, it was decided that the following changes will be made to the WellCare of South Carolina Medicaid Preferred Drug List (PDL), effective May 15, 2014. Please carefully review these changes. Key UPPER CASE = Brand Name Drugs Lower case italics = Generic Drugs PDL = Preferred Drug List

PA = Prior Authorization QL = Quantity Limits ST = Step Therapy

Effective date of change: May 15, 2014 Drug Name

Therapeutic Class

Change

PDL Alternative (if applicable)

ADDITIONS TO THE PDL A-METHAPRED injection solution reconstituted  40 mg; 125 mg

Corticosteroid; Glucocorticosteroid

Added to the PDL

AVANDAMET tablets  2-500 mg; 2-1000 mg; 4-1000 mg; 4500 mg

Antidiabetic Combination: ThiazolidinedioneBiguanide Combination

Added to the PDL w/ ST: (trial/failure of metformin, metformin ER, RIOMET)

AVANDARYL tablets  4-1 mg; 4-2 mg; 44 mg; 8-2 mg; 8-4 mg

Antidiabetic Combination: SulfonylureaBiguanide Combination

Added to the PDL w/ ST: (trial/failure of metformin, metformin ER, RIOMET)

AVANDIA tablets  2 mg; 4 mg; 8 mg

Antidiabetic; Insulin Sensitizing Agent; Thiazolidinedione

Added to the PDL w/ ST: (trial/failure of metformin, metformin ER, RIOMET)

CENTRATEX 106 - 1 mg oral capsule

Hematopoietic Mixture; Iron Combination

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Drug Name

Therapeutic Class

Change

cephalexin 750 mg capsules

Cephalosporin - 1st Generation

Added to the PDL

estradiolnorethindrone acetate tablets  0.5-0.1 mg; 1-0.5 mg

Estrogen Combination; Estrogen & Progestin

Added to the PDL

fondaparinux sodium subcutaneous solution  2.5 mg/ 0.5mL; 5 mg/ 0.4mL; 7.5 mg/ 0.6mL; 10 mg/0.8 mL

Anticoagulant; Heparin And Heparinoid-Like Agent; Synthetic Heparinoid-Like Agent

Added to the PDL w/ QL (varies by strength)

FORTICAL nasal solution 200 unit/ actuation

Bone Density Regulator; Calcitonin

Added to the PDL

GIANVI tablet 3-0.02 mg; LORYNA tablet 30.02 mg; NOR-QD tablet 0.35 mg; NORTREL 1/35 (28) tablet 1-35 mg-mcg; OCELLA tablet 3-0.03 mg; SYEDA tablet 30.03 mg; ZARAH tablet 3-0.03 mg; ZENCHENT FE tablet chewable 0.4-35 mgmcg

Contraceptives

Added to the PDL

glipizide-metformin hcl tablets  2.5-250 mg; 2.5500 mg; 5-500 mg

Antidiabetic Combination: SulfonylureaBiguanide Combination

Added to the PDL

levocarnitine oral solution 1 g/ 10 mL levocarnitine intravenous solution 200 mg/ mL

levocarnitine 330 mg tablets

Endocrine And Metabolic Agent; Metabolic Modifier; Carnitine Replenisher - Agent Endocrine And Metabolic Agent; Metabolic Modifier; Carnitine Replenisher - Agent

PDL Alternative (if applicable)

Added to the PDL w/ QL (900 mL/ 31 days) Added to the PDL

Added to the PDL

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Drug Name

Therapeutic Class

Change

lidocaine hcl (cardiac) intravenous solution 20 mg/ mL

Antiarrhythmic Type I-B

Added to the PDL

MAKENA oil IM 250 mg/ mL

Progestin

Added to the PDL w/ PA

methitest 10 mg tablets

Androgen Anabolic; Androgen

Added to the PDL

Corticosteroid; Glucocorticosteroid

Added to the PDL

metoprolol succinate er tablet extended release 24 hr  25 mg; 50 mg; 100 mg; 200 mg

Beta Blocker; Cardio-Selective

Added to the PDL

my way 1.5 mg tablets

Emergency Contraceptive

Added to the PDL

oxandrolone tablets  2.5 mg; 10 mg

Androgen - Anabolic Steroid

Added to the PDL w/ PA

pilocarpine 2% eye drops

Opthalmic Agent; Miotic - Direct Acting

Added to the PDL

PREMARIN injection solution reconstituted 25 mg

Estrogen

Added to the PDL

PREMPRO tablets  0.3-1.5 mg; 0.451.5 mg; 0.625-2.5 mg; 0.625-5 mg

Estrogen Combination; Estrogen & Progestin

Added to the PDL

PROLIA subcutaneous solution 60 mg/ mL

Bone Density Regulator; RANK Ligand (RANKL) Inhibitor

Added to the PDL w/ PA

methylprednisolone acetate injection suspension  40 mg/ mL; 80 mg/ mL methylprednisolone sodium succinate injection solution reconstituted  40 mg; 125 mg; 1000 mg; 1 gm

PDL Alternative (if applicable)

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Drug Name

Therapeutic Class

Change

propranolol hcl er capsule extended release 24 hour  60 mg; 80 mg; 120 mg; 160 mg

Beta Blocker; Beta Blocker NonSelective

Added to the PDL

ramipril capsules  1.25 mg; 2.5 mg; 5 mg; 10 mg

Antihypertensive; ACE Inhibitor

Added to the PDL

Beta Blocker; Beta Blocker NonSelective

Added to the PDL

TESTIM 1% transdermal gel

Androgen Anabolic; Androgen

Added to the PDL w/ PA

torsemide tablets  5 mg; 10 mg; 20 mg; 100 mg

Loop Diuretic

Added to the PDL

UNITHROID tablets all strengths

Thyroid Hormone

Added to the PDL

verapamil hcl er capsule 24 hour  100 mg; 120 mg; 180 mg; 200 mg; 240 mg; 300 mg; 360 mg

Calcium Channel Blocker

Added to the PDL

ZETIA 10 mg tablets

Antihyperlipidemic; Intestinal Cholesterol Absorption Inhibitor

Added to the PDL w/ PA

SORINE tablets  80 mg; 120 mg; 160 mg; 240 mg sotalol af tablets  80 mg; 120 mg; 160 mg

PDL Alternative (if applicable)

UTILIZATION MANAGEMENT CHANGES ACCU-CHEK test strips  Active; Aviva; Aviva Plus; Comfort Curve; Compact; Smartview

Diagnostic Product; Diagnostic Test

Updated QL: 200 test strips/31 days for members 21 years and younger; 100 test strips/31 days for members over 21 years

alendronate sodium tablets  5 mg; 10mg; 40mg; 70 mg

Bone Density Regulator; Biphosphonate

Removed QL

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Drug Name

Therapeutic Class

ALTAVERA tablet; APRI tablet; AVIANE tablet; AZURETTE tablet; BALZIVA tablet; briellyn tablet; CAMILA tablet; CAZIANT tablet; CRYSELLE-28 tablet; CYCLAFEM 1/35 tablet; CYCLAFEM 7/7/7 tablet; EMOQUETTE tablet; ENPRESSE-28 tablet; ERRIN tablet; ESTARYLLA tablet; GILDESS 1.5/30 tablet; GILDESS 1/20 tablet; JOLIVETTE tablet; JUNEL 1.5/30 tablet; JUNEL 1/20 tablet; JUNEL FE 1.5/30 tablet; JUNEL FE 1/20 tablet; KARIVA tablet; Contraceptives KELNOR 1/35 TABLET; LESSINA tablet; LEVORA 0.15/30 (28) tablet; LOW-OGESTREL tablet; LUTERA tablet; MICROGESTIN 1.5/30 tablet; MICROGESTIN 1/20 tablet; MICROGESTIN FE 1.5/30; MICROGESTIN FE 1/20 tablet; MONONESSA tablet; NECON 0.5/35 (28) tablet; NECON 1/35 (28) tablet; NECON 1/50 (28) tablet; NECON 7/7/7 tablet; NORA-BE tablet; norethindrone tablet; norgestim-eth estrad triphasic tablet; NORTREL 0.5/35 (28) tablet; NORTREL 1/35

Change

PDL Alternative (if applicable)

Removed QL

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(21) tablet; NORTREL 7/7/7 tablet; NUVARING vaginal ring 0.12-0.015 mg/24hr; ORSYTHIA tablet; PORTIA-28 tablet; PREVIFEM tablet; RECLIPSEN tablet; SOLIA tablet; SPRINTEC 28 tablet; SRONYX tablet; TRIESTARYLLA tablet; TRINESSA (28) tablet; TRI-PREVIFEM tablet; TRI-SPRINTEC tablet; TRIVORA (28) tablet; VELIVET tablet; ZOVIA 1/35E (28) tablet; ZOVIA 1/50E (28) tablet amlodipine besylate tablets  2.5 mg; 5 mg; 10 mg

Calcium Channel Blocker

Removed QL

atorvastatin tablets  10 mg; 20 mg; 40 mg; 80 mg

Antihyperlipidemic; HMG CoA Reductase Inhibitor

Removed ST

calcitonin (salmon) nasal solution 200 unit/ actuation

Bone Density Regulator; Calcitonin

Removed QL

cartia xt capsule extended release 24 hour  120 mg;180 mg; 240 mg; 300 mg

Calcium Channel Blocker

Removed QL

carvedilol tablets  3.125 mg; 6.25 mg; 12.5 mg

Beta Blocker; AlphaBeta Blocker

Removed QL

Otic Agent; Otic Steroid-AntiInfective Combination

Updated AL: Covered for members ≤ 6, covered with ST for members >6 (trial/failure of ofloxacin 0.3% ear drops)

CIPRODEX 0.3-0.1% otic suspension

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Drug Name

Therapeutic Class

Change

desmopressin acetate  rhinal tube nasal solution 0.01 %  spray refrig nasal solution 0.01 %  spray nasal solution 0.01 %  0.1 mg, 0.2 mg tablets

Endocrine And Metabolic Agent; Posterior Pituitary Hormone; Vasopressin

Removed QL

desmopressin acetate injection solution 4 mcg/ mL

Endocrine And Metabolic Agent; Posterior Pituitary Hormone; Vasopressin

Removed PA

dilt-xr capsule extended release 24 hour  120 mg; 180 mg; 240 mg

Calcium Channel Blocker

Removed QL

diltiazem hcl er beads capsule extended release 24 hour  120 mg; 180 mg; 240 mg; 300 mg; 360 mg; 420 mg

Calcium Channel Blocker

Removed QL

diltiazem hcl er capsule extended release 12 hour  60 mg; 90 mg; 120 mg

Calcium Channel Blocker

Removed QL

diltiazem hcl er capsule extended release 24 hour 240 mg

Calcium Channel Blocker

Removed QL

Calcium Channel Blocker

Removed QL

diltiazem hcl er coated beads capsule extended release 24 hour  120 mg; 180 mg; 240 mg; 300 mg; 360 mg

PDL Alternative (if applicable)

diltiazem hcl cd capsule extended release 24 hour 360 mg Page 7 of 19

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Drug Name

enoxaparin sodium injection solution 300mg/ 3mL

Therapeutic Class Anticoagulant; Heparin And Heparinoid-Like Agent; Low Molecular Weight Heparin

Change

Updated QL: 24 mL/ 31 days

 fluphenazine hcl oral elixir 2.5 mg/ 5 mL

fluphenazine hcl oral concentrate 5 mg/ mL



Antipsychotic/Antim anic Agent; Phenothiazine

 

Added AL: min 18 years QL (2480 mL/ 31 days) remains Added AL: min 18 years QL (248 mL/ 31 days) remains

fluphenazine hcl tablets  1 mg; 2.5 mg; 5 mg; 10 mg

Added AL: min 18 years

FREESTYLE test strips  Freestyle; Insulinx; Lite

Updated QL: 200 strips/ 31 days for members 21 years & younger; 100 strips/ 31 days for members over 21 years

    

HUMALOG KWIKPEN HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 KWIKPEN HUMULIN N U100 PEN HUMULIN 70/30 PEN

JANUMET XR extended release 24 hour tablets  100 mg-1000 mg  50 mg-1000 mg  50 mg-500 mg

Diagnostic Product; Diagnostic Test

Antidiabetic; Insulin; Human Insulin

Antidiabetic; Insulin; Human Insulin

Antidiabetic Combination: Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combination

PDL Alternative (if applicable)

 

Removed PA QL 60 mL/ 31 days remains

 

Removed PA QL 60 mL/31 days OTC Covered w/ RX



Removed QL

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Drug Name

Therapeutic Class

Change

JANUMET tablets  50 mg-1000 mg  50 mg-500 mg

Dipeptidyl Peptidase-4 Inhibitor-Biguanide

JANUVIA tablets  25 mg, 50 mg, 100 mg

Antidiabetic; Dipeptidyl Removed QL Peptidase-4 (DPP-4) Inhibitor

LANTUS SOLOSTAR pre-filled pen solution for injection

Antidiabetic; Insulin; Human Insulin

LATUDA tablets  20 mg; 40 mg; 60 mg; 80 mg; 120 mg

Antipsychotic/Antim anic Agent; Antipsychotic - Misc.

Updated ST: (trial/failure of 2: risperidone, quetiapine, olanzapine)

levonorgestrel 0.75 mg tablets

Contraceptive; Emergency Contraceptive

Updated QL: 4 tablets/ 31 days

losartan potassium tablets  25 mg; 50 mg; 100 mg

Antihypertensive; Angiotensin II Receptor Antagonist

Updated QL: 31 tablets/ 31 days

losartan potassiumHCTZ tablets  100-12.5 mg  100-25 mg  50-12.5 mg

Antihypertensive Combination; Angiotensin II Receptor Antag & Thiazide/ThiazideLike

Updated QL: 31 tablets/ 31 days

lovastatin tablets  10 mg; 20 mg; 40 mg

Antihyperlipidemic; HMG CoA Reductase Inhibitor

Removed QL

MATZIM LA tablet extended release 24 hour  180 mg; 240 mg; 300 mg; 360 mg; 420 mg

Calcium Channel Blocker

Removed QL

megestrol acetate 40 mg/ mL oral suspension

Antineoplastic And Adjunctive Therapy; Hormonal And Related Agent; Progestin

Added QL: 600 mL/ 31 days

PDL Alternative (if applicable)

Removed QL

 

Removed PA QL 60 mL/ 31 days remains

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Drug Name next choice one dose 1.5 mg tablet

Therapeutic Class

Change

Contraceptive; Emergency Contraceptive

Removed QL

Calcium Channel Blocker

Removed QL

Antianginal Agent; Nitrate

Removed QL

Anticonvulsant Benzodiazepine

Added ST: 31 day trial/failure of 2: lamotrigine, divalproex or topiramate

PDL Alternative (if applicable)

nifediac cc tablet extended release 24 hour  30 mg; 60 mg; 90 mg nifedical XL tablet extended release 24 hour  30 mg; 60 mg nifedipine er tablet extended release 24 hour  30 mg; 60 mg; 90 mg nifedipine er osmotic tablet extended release 24 hr  60 mg; 90 mg nitroglycerin transdermal patch 24 hr  0.1 mg/ hr; 0.2 mg/ hr; 0.4 mg/ hr; 0.6 mg/ hr ONFI tablets  5 mg; 10 mg; 20 mg

 

pioglitazone hcl tablets  15 mg; 30 mg; 45 mg

Antidiabetic; Insulin Sensitizing Agent; Thiazolidinedione

pioglitazone hcl – metformin hcl tablets  15 mg-500 mg  15 mg-850 mg

Antidiabetic Combination: ThiazolidinedioneBiguanide Combination

Removed QL ST remains (93 day trial of 1500 mg/ day of metformin, metformin ER, RIOMET)

Removed QL

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Drug Name pravastatin sodium tablets  10 mg; 20 mg; 40 mg; 80 mg

Therapeutic Class Antihyperlipidemic; HMG CoA Reductase Inhibitor

Removed QL

PRECISION XTRA test strips

Diagnostic Product; Diagnostic Test

Updated QL: 200 strips/ 31 days for members 21 years and younger; 100 strips/ 31 days for members over 21 years

RIOMET 500 mg/ 5 mL oral solution

Antidiabetic; Biguanide

Added QL: 900 mL/ 31 days

SAPHRIS sublingual tablets  5 mg; 10 mg

Antipsychotic/Antim anic Agent; Dibenzo-oxepino Pyrrole

Added AL  Members < 18 years: PA required  ≥ 18 years: covered w/ ST: (trial/failure of 2: risperidone, quetiapine, olanzapine)

simvastatin tablets  5 mg; 10 mg; 20 mg; 40 mg; 80 mg

Antihyperlipidemic; HMG CoA Reductase Inhibitor

Removed QL

vitamin D (ergocalciferol) capsule 50000 unit

Oil Soluble Vitamin; Vitamin D

Added QL: 4 capsules/ 28 days

XARELTO 10 mg tablets

PDL Alternative (if applicable)

Change

 Anticoagulant; Direct  Factor Xa Inhibitor

Removed PA Added QL: 35 tablets/ 365 days

REMOVALS FROM THE PDL acebutolol hcl capsules  200 mg; 400 mg acetazolamide capsule extended release 12 hour 500 mg

Beta Blocker; Beta Blocker CardioSelective

Removed from the PDL

Diuretic; Carbonic Anyhydrase Inhibitor

Removed from the PDL

  

atenolol tablets bisoprolol tablets metoprolol tartrate tablets



acetazolamide tablets methazolamide tablets



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Drug Name

Therapeutic Class

Change

PDL Alternative (if applicable)

ACTOPLUS MET XR tablet extended release 24 hr  15 mg-1000 mg  30 mg-1000 mg

Antidiabetic Combination: ThiazolidinedioneBiguanide Combination

Removed from the PDL

pioglitazone-metformin tablets  15 mg-500 mg  15 mg-850 mg

ADCIRCA 20 mg tablets

Cardiovascular Agent; Pulmonary Hypertension Phosphodiesterase Inhibitor

Removed from the PDL

sildenafil citrate 20 mg tablet (PA)

alyacen 1/35 tablet; alyacen 7/7/7 tablet; ARANELLE tablet; DASETTA 1/35 tablet; DASETTA 7/7/7 tablet; ELINEST tablet; ENSKYCE tablet; FALMINA tablet; GILDAGIA tablet; GILDESS FE 1.5/30 tablet; GILDESS FE 1/20 tablet; JENCYCLA tablet; KURVELO tablet; LEENA tablet; LEVONEST tablet; levonorgestrel-ethinyl Contraceptives estrad tablet; marlissa tablet; MONO-LINYAH tablet; MYZILRA tablet; NECON 10/11 (28) tablet; NORINYL 1+50 (28) tablet; OGESTREL tablet; ORTHO EVRA transdermal patch weekly, PHILITH tablet; TILIA FE tablet; TRI-LEGEST FE tablet; TRI-LINYAH tablet; viorele tablet; WERA tablet; ZENCHENT tablet tablet

Removed from the PDL

Refer to the PDL for a full list of covered contraceptives

amiloride hcl 5 mg tablets

Removed from the PDL

spironolactone tablets  25 mg, 50 mg, 100 mg

Diuretic; Potassium Sparing Diuretic

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Drug Name

Therapeutic Class

PDL Alternative (if applicable)

Change

aminocaproic acid 500 mg tablet

Hemostatic Systemic

Removed from the PDL

ARANESP (albumin free) injection solution – all strengths

Hematopoietic Growth Factor; ErythropoiesisStimulating Agent

Removed from the PDL

BERINERT intravenous kit 500 unit

Hematological Agent Removed from the - Misc.; Complement PDL Inhibitor; C1 Inhibitor

budesonide er capsule Corticosteroid; extended release 24 Glucocorticosteroid hour 3 mg

Removed from the PDL

CENESTIN tablets  0.3 mg; 0.45 mg; 0.625 mg; 0.9 mg

Estrogen

cephalexin tablets  250 mg; 500 mg

PROCRIT – all strengths (PA)

 

cortisone 25 mg tablets prednisone tablets

Removed from the PDL

 

estradiol tablets PREMARIN tablets

Cephalosporin - 1st Generation

Removed from the PDL

cephalexin 250 mg, 500 mg capsules

clonidine hcl transdermal patch  0.1 mg/ 24hr; 0.2 mg/ 24hr; 0.3 mg/ 24hr

Antihypertensive; Antiadrenergic Centrally Acting

Removed from the PDL

clonidine 0.1 mg, 0.2 mg, 0.3 mg tablets

DIURIL 250 mg/ 5 mL oral suspension

Diuretic; Thiazides And Thiazide-Like Diuretic

Removed from the PDL

clonidine 0.1 mg, 0.2 mg, 0.3 mg tablets

DROXIA capsules  200 mg; 300 mg; 400 mg

Hematopoietic Agent; Agent For Sickle Cell Anemia; Cytotoxic Agent

Removed from the PDL

ELIQUIS tablets  2.5 mg; 5 mg

Anticoagulant; Direct Removed from the Factor Xa Inhibitor PDL

ENJUVIA tablets  0.3 mg; 0.45 mg; 0.625 mg; 0.9 mg; 1.25 mg

Estrogen

epinephrine autoinjectors  0.15 mg/0.15 mL  0.3 mg/0.3 mL

Removed from the PDL

Vasopressor; Anaphylaxis Therapy Agent

Removed from the PDL

XARELTO 10 mg tablets (QL)  

estradiol tablets PREMARIN tablets



EPIPEN 2-PAK injection device 0.3 mg/ 0.3 mL (QL) EPIPEN JR 2-PAK injection device 0.15 mg/ 0.3 mL (QL)



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Drug Name

Therapeutic Class

PDL Alternative (if applicable)

Change

EPOGEN vials (all strengths)

Hematopoietic Growth Factor; ErythropoiesisStimulating Agent

Removed from the PDL

PROCRIT - all strengths (PA)

etidronate disodium tablets  200 mg; 400 mg

Bone Density Regulator; Biphosphonate

Removed from the PDL

alendronate tablets

felodipine er tablet extended release 24hr  2.5 mg; 5 mg; 10 mg

Calcium Channel Blocker

Removed from the PDL

  

amlodipine tablets dilt-xr capsules nifedical xl tablets



ferrous sulfate tablets (OTC – Covered with Rx) folic acid tablets (OTC – Covered with Rx)

FERREX 28 tablets

Hematopoietic Agent; Iron

Removed from the PDL



ferrous fumarate 324 mg tablets

Hematopoietic Agent; Iron

Removed from the PDL

ferrous sulfate 325mg tablets (OTC – Covered with Rx)

ferrous gluconate tablets  240 mg; 324 mg; 325 mg

Hematopoietic Agent; Iron

Removed from the PDL

ferrous sulfate 325mg tablets (OTC – Covered with Rx)

FORTEO subcutaneous solution 600 mcg/ 2.4mL

Bone Density Regulator; Parathyroid Hormone And Derivative

Removed from the PDL

calcitonin-salmon 200unit/ actuation nasal spray 

Antihypertensive fosinopril - HCTZ Combination; ACE tablets Inhibitor &  10 mg-12.5 mg; 20 Thiazide/Thiazidemg-12.5 mg Like

Removed from the PDL

heparin sodium (porcine) injection solution  5000 unit/ mL; 10000 unit/ mL

Anticoagulant; Heparin And Heparinoid-Like Agent

Removed from the PDL

INCRELEX subcutaneous solution 40 mg/ 4mL

Endocrine And Metabolic Agent; Insulin-like Growth Factor (Somatomedin)

Removed from the PDL

 

benazepril-hctz tablets enalapril-hctz tablets lisinopril-hctz tablets

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Drug Name

Therapeutic Class

PDL Alternative (if applicable)

Change

KOMBIGLYZE XR tablet extended release 24 hr  2.5 - 1000 mg; 5 1000 mg; 5 - 500 mg

Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combination

Removed from the PDL

KUVAN oral tablet soluble 100 mg

Metabolic Modifier; Phenylketonuria Treatment - Agent

Removed from the PDL

Hematopoietic Growth Factor; Granulocyte/Macrop hage ColonyStimulating Factor

Removed from the PDL

NEUPOGEN (PA)

Endocrine And Metabolic Agent; LHRH/GnRH Agonist Analog Pituitary Supressant

Removed from the PDL

TRELSTAR (PA)

LYSTEDA 650 mg tablets

Hemostatic Systemic

Removed from the PDL

MENOSTAR transdermal patch weekly 14 mcg/ 24hr

Estrogen

Removed from the PDL

methyldopa - hcl tablets  250-15 mg; 25025 mg

Antihypertensive Combinations; Adrenolytic-Central & Thiazide/ThiazideLike

Removed from the PDL



methylprednisolone 4 mg tablet

Corticosteroid; Glucocorticosteroid

Removed from the PDL

prednisone 1mg, 2.5mg, 5mg, 10mg, 20mg tablets

metoprolol tartate intravenous solution  1 mg/ mL; 5 mg/ 5mL

Beta Blocker; Beta Blocker CardioSelective

Removed from the PDL

metoprolol tartrate 50mg, 100mg tablets

LEUKINE injection solution 500 mcg/ mL LEUKINE intravenous solution reconstituted 250 mcg LUPRON DEPOTPED Intramuscular kit  11.25 mg; 11.25 mg (PED); 15 mg; 30 mg (PED); 7.5 mg LUPRON DEPOT intramuscular kit  11.25 mg; 22.5 mg; 3.75 mg; 30 mg; 45 mg; 7.5 mg

 

JANUMET tablets (ST, QL) JENTADUETO (ST, QL)

estradiol transdermal patch 

methyldopa 250mg, 500mg tablets hydrochlorothiazide 12.5mg, 25mg, 50mg tablets

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Drug Name

Therapeutic Class

PDL Alternative (if applicable)

Change

MIACALCIN injection solution 200 unit/ mL

Bone Density Regulator; Calcitonin

Removed from the PDL

calcitonin-salmon 200unit/ actuation nasal spray

nateglinide tablets  60 mg; 120 mg

Antidiabetic; Meglitinide Analogue

Removed from the PDL

NEULASTA subcutaneous solution 6 mg/ 0.6 mL

Hematopoietic Growth Factor; Granulocyte ColonyStimulating Factor

Removed from the PDL

NEUPOGEN (PA)

NEUMEGA subcutaneous solution reconstituted 5 mg

Hematopoietic Growth Factor; Interleukin

Removed from the PDL

NEUPOGEN (PA)

NIASPAN extendedrelease tablets  500 mg; 1000 mg

Antihyperlipidemic; Nicotinic Acid Derivative

Removed from the PDL

 

niacin er 750mg tablet niacor 500mg tablet

nicardipine hcl capsules  20 mg; 30 mg

  

amlodipine tablets diltiazem tablets verapamil tablets

nifedipine capsules  10 mg; 20 mg

  

amlodipine tablets diltiazem tablets verapamil tablets

 

nifediac cc tablets nifedical xl tablets

nifedipine er tablet extended release 24 hr  30 mg; 60 mg; 90 mg

Calcium Channel Blocker

Removed from the PDL

nimodipine 30 mg capsules

 amlodipine tablets  diltiazem tablets  verapamil tablets NITROSTAT 0.3mg, 0.4mg, 0.6mg SL tablets

nitroglycerin translingual solution 0.4 mg/ spray

Antianginal Agent; Nitrate

Removed from the PDL

NORPACE CR capsule extendedrelease 12 hour  100 mg; 150 mg

Antiarrhythmic; Antiarrhythmic Type I-A

Removed from the PDL

disopyramide phosphate 100mg, 150mg capsules

NOVOLIN 70-30 vial

Antidiabetic; Insulin; Human Insulin

Removed from the PDL

HUMULIN 70-30 vial (QL; OTC – Covered with Rx)

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Drug Name

Therapeutic Class

PDL Alternative (if applicable)

Change

octreotide acetate injection solution  50 mcg/ mL; 100 mcg/ mL; 200 mcg/ mL; 500 mcg/ mL; 1000 mcg/ mL

Endocrine And Metabolic Agent Misc; Somatostatic Agent

ONGLYZA tablets  2.5 mg; 5 mg

Antidiabetic; Dipeptidyl Removed from the Peptidase-4 (DPP-4) PDL Inhibitor

pioglitazone hclglimepiride  30 mg-2 mg; 30 mg-4 mg

Antidiabetic Combination: SulfonylureaThiazolidinedione Combination

Removed from the PDL

prednisone (pak) tablet  5 mg; 10 mg

Corticosteroid; Glucocorticosteroid

Removed from the PDL

prednisone 1mg, 2.5mg, 5mg, 10mg, 20mg tablets

PREDNISONE INTENSOL oral concentrate 5 mg/ mL

Corticosteroid; Glucocorticosteroid

Removed from the PDL

prednisone 5mg/ 5mL oral solution

PROMACTA tablets  25 mg; 50 mg; 75 mg

Thrombopoietin (Tpo) Receptor Agonist

Removed from the PDL

propranolol hcl oral solution  20 mg/ 5 mL; 40 mg/ 5 mL

Beta Blocker; Beta Blocker NonSelective

Removed from the PDL

quinapril-hcl tablets  10-12.5 mg; 2012.5 mg; 20-25 mg

Antihypertensive Combinations; ACE Inhibitor & Thiazide/ThiazideLike

Removed from the PDL

quinidine sulfate tablets  200 mg; 300 mg

Antiarrhythmic; Antiarrhythmic Type I-A

Removed from the PDL

quinidine gluconate ER 324mg tablet

quinidine sulfate er tablet extended release 300 mg

Antiarrhythmic; Antiarrhythmic Type I-A

Removed from the PDL

quinidine gluconate ER 324mg tablet

Removed from the PDL

   

JANUVIA 25mg, 50mg, 100mg tablets (ST, QL) TRADJENTA 5mg tablets (ST, QL) pioglitazone 15mg, 30mg, 45mg tablets (ST) glimepiride 1mg, 2mg, 4mg tablets

propranolol 10mg, 20 mg, 40 mg, 60 mg, 80 mg tablets   

benazepril-hctz tablets enalapril-hctz tablets lisinopril-hctz tablets

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Drug Name

Therapeutic Class

PDL Alternative (if applicable)

Change   

amlodipine tablets atenolol tablets metoprolol tablets

 

simvastatin tablets niacin er 750mg tablets niacor 500mg tablets

RANEXA tablet extended release 12hr  500 mg; 1000 mg

Antianginal Agent; Antianginal-Other

Removed from the PDL

repaglinide tablets  0.5 mg; 1 mg; 2 mg

Antidiabetic; Meglitinide Analogue

Removed from the PDL

SIMCOR tablet extended release 24hr  500-20 mg; 50040 mg; 750-20 mg; 1000-20 mg; 1000-40 mg

Antihyperlipidemic; HMG CoA Reductase Inhibitors Combination

Removed from the PDL

SYMLINPEN 120 subcutaneous solution 2700 mcg/ Antidiabetic; 2.7mL Antidiabetic - Amylin SYMLINPEN 60 Analog subcutaneous solution 1500 mcg/ 1.5mL

Removed from the PDL

 







HUMULIN vial LANTUS vial

TIKOSYN capsules  125 mcg; 250 mcg; 500 mcg

Antiarrhythmic; Antiarrhythmic Type III

Removed from the PDL

amiodarone 200mg, 400mg tablets

tolazamide tablets  250mg; 500 mg

Antidiabetic; Sulfonylurea

Removed from the PDL

  

glimiperide tablets glipizide tablets glyburide tablets

tolbutamide 500 mg tablets

Antidiabetic; Sulfonylurea

Removed from the PDL

  

glimiperide tablets glipizide tablets glyburide tablets

TRACLEER tablets  62.5 mg; 125 mg

Pulmonary Hypertension Endothelin Receptor Antagonist

Removed from the PDL

LETAIRIS (PA)

UNITHROID DIRECT tablets (all strengths)

Thyroid Agent; Thyroid Hormone

Removed from the PDL

UNITHROID tablets (all strengths)

VICTOZA 18 mg/ 3mL pen injectors  2-pak; 3-pak

Incretin Mimetic Agent (GLP-1 Receptor Agonist)

Removed from the PDL

BYDUREON (ST, QL)

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Drug Name

Therapeutic Class

VYTORIN tablets  10-10 mg; 10-20 mg; 10-40 mg; 1080 mg

Antihyperlipidemic Combination; Intest Cholest Absorp Inhib-HMG CoA Reductase Inhib Comb

XARELTO tablets  15 mg; 20 mg

Anticoagulant; Direct Removed from the Factor Xa Inhibitor PDL

PDL Alternative (if applicable)

Change

Removed from the PDL

 

simvastatin tablets ZETIA tablets (PA)

XARELTO 10 mg tablets (QL)

If you have questions, WellCare of South Carolina’s Pharmacy Help Desk and its affiliated vendor, Catamaran, are available to assist providers seven days a week, 24 hours a day at 1-888-5889842. Thank you for your care of WellCare of South Carolina Medicaid members. Sincerely, WellCare of South Carolina

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