UPDATE
HealthEase/Staywell Medicaid
Preferred Drug List
April 3, 2014
Dear Provider:
At the February 27, 2014 WellCare Pharmacy & Therapeutics Committee meeting, it was
decided that the following changes will be made to the HealthEase/Staywell 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
 azurette tablets
 cyclafem 1/35 tablets
 cyclafem 7/7/7 tablets
 gildess 1.5/30 tablets
 gildess 1/20 tablets
 norethindrone 0.35 mg
tablets
 norgestimate/ethinyl
estradiol tablets
 nor-q-d tablets
 orsythia tablets
 zarah tablets
Contraceptives
Added to the PDL
pilocarpine 2%
ophthalmic drops
Ophthalmic Agent;
Miotic - Direct Acting
Added to the PDL
UTILIZATION MANAGEMENT CHANGES
atorvastatin tablets
 10 mg
 40 mg
 20 mg
 80 mg
CIPRODEX 0.3 - 0.1%
otic suspension
Antihyperlipidemic;
HMG CoA
Reductase Inhibitor
Removed ST
Otic Agent; Otic
Steroid-AntiInfective
Combination
Updated AL:
members ≤ 6 =
covered; members >
6 = covered with ST
(trial/failure of
Ofloxacin 0.3% otic
drops)
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Drug Name
dextroamphetamine
sulfate extended-release
capsules
Therapeutic Class
Change
Central Nervous
System Agent;
ADHD Agent,
Amphetamine
Updated AL: min: 6y,
max: 20y; QL
remains: 31 capsules
/31 days; ST
remains: trial/failure
of Vyvanse or
Adderall XR
fluphenazine 2.5 mg /5
mL elixir
Antipsychotic/Antim
anic Agent;
Phenothiazine
Added AL: min 18y;
QL remains (2480
mL/ 31 days)
fluphenazine 5 mg /mL
concentrate
Antipsychotic/Antim
anic Agent;
Phenothiazine
Added AL: min 18y;
QL remains (248 mL/
31 days)
fluphenazine tablets
 1 mg
 5 mg
 2.5 mg
 10 mg
Antipsychotic/Antim
anic Agent;
Phenothiazine
Added AL: min 18y
 5 mg
 10 mg
 15 mg
PDL Alternative
(if applicable)
REMOVALS FROM THE PDL
UNITHROID DIRECT
150 mcg tablets
Thyroid Agent;
Thyroid Hormone
Removed from the
PDL
UNITHROID 150
mcg tablet
VYTORIN tablets
Antihyperlipidemic Combination; Intest
Cholest Absorp
Inhib - HMG CoA
Reductase Inhib
Comb
Removed from the
PDL
 simvastatin
tablets
 ZETIA tablets
 10/10 mg  10/40 mg
 10/20 mg  10/80 mg
If you have questions, HealthEase/Staywell Health Plan’s Pharmacy Help Desk and its affiliated
vendor, Catamaran Rx, are available to assist providers seven days a week, 24 hours a day at 1877-647-7473.
Thank you for your care of HealthEase/Staywell Medicaid members.
Sincerely,
HealthEase/Staywell Health Plans
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