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WellCare Health Plan Kentucky Medicaid
2012 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) WellCare of Kentucky 00 9 Please read: This document contains information about the drugs we cover in this plan. Please note that the WellCare of Kentucky Medicaid Preferred Drug List is updated quarterly. Providers, please visit our website at www.kentucky.wellcare.com/provider/resources to view updates to the preferred drug list. Members, please visit our website at www.kentucky.wellcare.com/members to view updates to the preferred drug list. Last updated (07/01/2012) WC02201237 WC - MCD_Provider_Kentucky_PDL 7/06/12 WellCare of Kentucky Medicaid Cough & Cold Drug List Non-Formulary Drugs Preferred Formulary Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl ALLANHIST PDX DROPS BROMFED DM SYRUP BROMHIST PDX DROPS ENDACOF-PD DROPS C-PHEN DM PD-COF SYRUP RONDEX-DM SYRUP SILDEC PE-DM SYRUP BROTAPP DM LIQUID Q-TAPP DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl DE-CHLOR DM LIQUID NOHIST-DM Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Dextromethorphan HBr/Promethazine HCl PROMETHAZINE-DM SYRUP Dextromethorphan HBr/Pseudoephedrine HCl/Chlorpheniramine PEDIATRIC COUGH-COLD LIQUID EXPECTORANTS Guaifenesin MUCINEX 600 MG TABLET GUAIFENESIN 200 MG TABLET PV CHEST CONGESTION RLF CPLT GUAIFENESIN 400 MG TABLET REFENESEN 400 MG TABLET DECONGESTANT-EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl DONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID RESCON-GG LIQUID NON-NARCOTIC DECONGESTAN-EXPECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR SU-TUSS DM ELIXIR GANI-TUSS-DM NR LIQUID GUAIFENESIN DM SYRUP IOPHEN DM-NR LIQUID Last updated 02/23/12 MUCUS RELIEF COUGH LIQUID Q-TUSSIN-DM SYRUP SILTUSSIN DM COUGH SYRUP Page 1 of 2 WellCare of Kentucky Medicaid Cough & Cold Drug List Non-Formulary Drugs Preferred Formulary Drugs NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex TUSSIONEX PENNKINETIC SUSP TUSSICAPS Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP HC/PE/DBROM SYRUP Codeine/Phenylephrine HCl/Promethazine PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROMET SYRUP HYDROCODONE-HOMATROPINE NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP Codeine Phosphate/Guaifenesin TUSSICLEAR DH SYRUP CHERATUSSIN AC SYRUP GANI-TUSS NR LIQUID GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP Last updated 02/23/12 Page 2 of 2 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class ANTIHISTAMINE DRUGS Derivatives, Miscellaneous Ethanolamine Derivatives Phenothiazine Derivatives Propylamine Derivatives Second Generation Antihistamines ANTI-INFECTIVE AGENTS Anthelmintics Aminoglycosides Glycopeptides Lincomycins Product Name Strengths Form Coverage Detail cyproheptadine hcl cyproheptadine hcl diphenhydramine hcl diphenhydramine hcl diphenhydramine hcl promethazine hcl promethazine hcl plain promethegan actanol altafed antihistamine/decongestant aprodine chlorpheniramine maleate genac silafed tri-afed allergy/head cold alavert allergy/sinus allergy 2MG/5ML 4MG 12.5MG/5ML 50MG 50MG, 25MG 50MG, 25MG, 12.5MG 6.25MG/5ML 50MG, 25MG, 12.5MG 60MG/ 2.5MG 30MG/5ML/ 1.25MG/5ML 60MG/ 2.5MG 60MG/ 2.5MG 4MG 60MG/ 2.5MG 30MG/5ML/ 1.25MG/5ML 60MG/ 2.5MG 5MG/ 120MG 10MG SYRP TABS LIQD CAPS TABS, CAPS TABS, SUPP SYRP SUPP TABS SYRP TABS TABS TABS TABS SYRP TABS TB12 TBDP, TABS QL (300.00 ML per 31 days) allergy relief allergy relief 5MG/5ML 10MG SYRP TABS allergy relief for kids 5MG/5ML SYRP Second Generation Cephalosporins OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx QL (300.00 ML per 31 days);OTCCovered w/Rx OTC-Covered w/Rx QL (300.00 ML per 31 days);OTCCovered w/Rx TB24 SYRP TABS cetirizine hcl children's 1MG/ML SOLN cetirizine hcl children's allergy cetirizine hcl/pseudoephedrine hcl er 5MG/5ML, 1MG/ML SYRP 5MG/ 120MG TB12 children's loratadine clear-atadine d fexofenadine hcl fexofenadine hcl/pseudoephedrine hcl er fexofenadine hcl/pseudoephedrine hcl er loratadine 5MG/5ML 10MG/ 240MG 30MG, 180MG, 60MG SYRP TB24 TABS OTC-Covered w/Rx QL (300.00 ML per 31 days);OTCCovered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx 180MG/ 240MG TB24 OTC-Covered w/Rx 60MG/ 120MG 10MG TB12 TABS loratadine hives relief 5MG/5ML SOLN reeses pinworm medicine TOBI vancomycin hcl vancomycin hcl clindamycin hcl clindamycin palmitate hcl 144MG/ML 300MG/5ML 250MG, 125MG 750MG, 500MG, 1000MG 300MG, 150MG, 75MG 75MG/5ML 900MG/6ML, 600MG/4ML, 300MG/2ML, 150MG/ML 1GM, 500MG/5ML, 250MG/5ML, 500MG 500MG, 1GM SUSP NEBU CAPS SOLR CAPS SOLR cefadroxil cefazolin sodium cephalexin cephalexin cefaclor cefprozil cefuroxime axetil Third Generation Cephalosporins OTC-Covered w/Rx allergy relief/nasal decongestant 10MG/ 240MG cetirizine hcl 5MG/5ML, 1MG/ML cetirizine hcl 5MG, 10MG clindamycin phosphate First Generation Cephalosporins OTC-Covered w/Rx cefdinir 125MG/5ML, 500MG, 250MG 250MG/5ML 500MG, 250MG 500MG, 250MG, 250MG/5ML, 125MG/5ML OTC-Covered w/Rx QL (300.00 ML per 31 days) OTC-Covered w/Rx QL (300.00 ML per 31 days);OTCCovered w/Rx QL (300.00 ML per 31 days);OTCCovered w/Rx OTC-Covered w/Rx QL (300.00 ML per 31 days);OTCCovered w/Rx OTC- Covered w/Rx PA PA QL (2400.00 ML per 31 days) SOLN TABS, SUSR, CAPS SOLR SUSR, CAPS SUSR CAPS QL (300.00 ML per 31 days) TABS, SUSR 500MG, 250MG, 125MG/5ML TABS, SUSR 250MG/5ML, 125MG/5ML, 300MG SUSR, CAPS UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 1 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name cefpodoxime proxetil SUPRAX E.E.S. 400 E.E.S. GRANULES ERYPED 200 ERYPED 400 ERY-TAB ERYTHROCIN STEARATE erythromycin erythromycin base erythromycin ethylsuccinate erythromycin/sulfisoxazole Erythromycins Other Macrolides azithromycin azithromycin clarithromycin Natural Penicillins BICILLIN C-R BICILLIN L-A PENICILLIN G PROCAINE penicillin v potassium Strengths 200MG, 100MG, 50MG/5ML, 100MG/5ML 400MG 400MG 200MG/5ML 200MG/5ML 400MG/5ML 500MG, 333MG, 250MG 250MG 250MG 500MG, 250MG 400MG 200MG/5ML/ 600MG/5ML 200MG/5ML, 100MG/5ML, 2.5GM, 500MG, 600MG 250MG 500MG, 250MG, 250MG/5ML, 125MG/5ML 900000UNIT/2ML/ 300000UNIT/2ML, 300000UNIT/ML/ 300000UNIT/ML 600000UNIT/ML, 2400000UNIT/4ML, 1200000UNIT/2ML 600000UNIT/ML 250MG/5ML penicillin v potassium pfizerpen-g Aminopenicillins Penicillinase-resistant Penicillins Quinolones Sulfonamides Tetracyclines Allylamines Antifungals, Miscellaneous Azoles Polyenes 500MG, 250MG, 125MG/5ML 5MU, 20MU 200MG/5ML, 125MG/5ML, 250MG, 125MG, 500MG, amoxicillin 875MG amoxicillin 400MG/5ML, 250MG/5ML 250MG/5ML/ 62.5MG/5ML, amoxicillin/clavulanate potassium 200MG/5ML/ 28.5MG/5ML 875MG/ 125MG, 500MG/ 125MG, 250MG/ 125MG, 600MG/5ML/ 42.9MG/5ML, 400MG/5ML/ 57MG/5ML, 400MG/ 57MG, 200MG/ amoxicillin/clavulanate potassium 28.5MG 250MG/5ML, 125MG/5ML, ampicillin 500MG, 250MG dicloxacillin sodium 500MG, 250MG oxacillin sodium 2GM, 1GM, 10GM ciprofloxacin hcl 750MG, 500MG, 250MG levofloxacin 750MG, 500MG, 250MG Form TABS, SUSR TABS TABS SUSR SUSR SUSR TBEC TABS CPEP TABS TABS SUSR SUSR, SOLR, TABS TABS Coverage Detail QL (1.00 EA per 31 days) QL (6.00 EA per 31 days) TABS, SUSR SUSP SUSP SUSP SOLR QL (300.00 ML per 31 days) TABS, SOLR SOLR SUSR, CHEW, CAPS, TABS SUSR QL (300.00 ML per 31 days) SUSR QL (300.00 ML per 31 days) TABS, SUSR, CHEW SUSR, CAPS CAPS SOLR TABS TABS 800MG/20ML/ 160MG/20ML, 200MG/5ML/ 40MG/5ML SUSP 400MG/ 80MG TABS sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim sulfamethoxazole/trimethoprim ds sulfasalazine doxycycline hyclate minocycline hcl tetracylcine hcl terbinafine hcl GRIFULVIN V griseofulvin microsize GRIS-PEG 800MG/ 160MG 500MG 20MG, 100MG, 50MG 75MG, 50MG, 100MG 500MG, 250MG 250MG 500MG 125MG/5ML 250MG, 125MG fluconazole ketoconazole nystatin 50MG, 200MG, 150MG, 100MG, 40MG/ML, 10MG/ML TABS, SUSR 200MG TABS 100000UNIT/ML SUSP TABS TBEC, TABS TABS, CAPS, SOLR CAPS CAPS TABS TABS SUSP TABS QL (14.00 EA per 31 days) QL (1200.00 ML per 31 days) QL (450.00 ML per 31 days) QL (300.00 ML per 31 days) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 2 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Antimycobacterials, Miscellaneous Antituberculosis Agents Antimalarials Antiprotozoals, Miscellaneous Adamantanes HIV Entry and Fusion Inhibitors HIV Protease Inhibitors Product Name nystatin DAPSONE ethambutol hcl isoniazid MYCOBUTIN pyrazinamide rifampin atovaquone/proguanil hcl DARAPRIM hydroxychloroquine sulfate mefloquine hcl PRIMAQUINE PHOSPHATE MEPRON metronidazole rimantadine hcl FUZEON SELZENTRY APTIVUS CRIXIVAN INVIRASE KALETRA LEXIVA LEXIVA NORVIR PREZISTA Integrase Inhibitors REYATAZ VIRACEPT ISENTRESS Nonnucleoside Reverse Transcriptase Inhibitors ATRIPLA COMPLERA EDURANT INTELENCE RESCRIPTOR SUSTIVA VIRAMUNE Nucleoside and Nucleotide Reverse Transcriptase Inhibitors didanosine EMTRIVA EMTRIVA EPIVIR EPIVIR HBV EPZICOM lamivudine lamivudine/zidovudine stavudine TRIZIVIR TRUVADA VIDEX PEDIATRIC Miscellaneous Antiretrovirals HCV Protease Inhibitors Interferons VIREAD ZIAGEN zidovudine zidovudine ATRIPLA INCIVEK VICTRELIS PEGASYS PEGASYS PROCLICK Strengths 500000UNIT 25MG, 100MG 400MG, 100MG 300MG, 100MG, 100MG/ML 150MG 500MG 600MG, 300MG, 150MG 62.5MG/ 25MG, 250MG/ 100MG 25MG 200MG 250MG 26.3MG 750MG/5ML 500MG, 250MG 100MG 90MG 300MG, 150MG 250MG 400MG, 200MG 500MG, 200MG 200MG/ 50MG, 100MG/ 25MG, 400MG/5ML/ 100MG/5ML 50MG/ML 700MG 100MG, 80MG/ML 75MG, 600MG, 400MG, 150MG 300MG, 200MG, 150MG, 100MG 625MG, 250MG 400MG Form TABS TABS TABS TABS, SOLN CAPS TABS SOLR, CAPS 600MG/ 200MG/ 300MG 200MG/ 25MG/ 300MG 25MG 200MG, 100MG 200MG, 100MG 600MG, 50MG, 200MG 200MG, 50MG/5ML 400MG, 250MG, 200MG, 125MG 200MG 10MG/ML 10MG/ML 100MG, 5MG/ML 600MG/ 300MG 300MG, 150MG 150MG/ 300MG 40MG, 30MG, 20MG, 15MG 300MG/ 150MG/ 300MG 200MG/ 300MG 4GM, 2GM 300MG, 250MG, 200MG, 150MG 300MG, 20MG/ML 50MG/5ML 300MG, 100MG 600MG/ 200MG/ 300MG 375MG 200MG 180MCG/ML, 180MCG/0.5ML, 180MCG/0.5ML 180MCG/0.5ML, 135MCG/0.5ML TABS TABS TABS TABS TABS TABS, CAPS TABS, SUSP Coverage Detail TABS TABS TABS TABS TABS SUSP TABS TABS KIT, SOLR TABS CAPS CAPS TABS, CAPS TABS, SOLN SUSP TABS TABS, CAPS, SOLN QL (124.00 EA per 31 days) TABS CAPS TABS TABS CPDR CAPS SOLN SOLN TABS, SOLN TABS TABS TABS CAPS TABS TABS SOLR QL (62.00 EA per 31 days) QL (310.00 EA per 31 days) QL (31.00 EA per 31 days) QL (31.00 EA per 31 days) QL (170.00 ML per 31 days) QL (31.00 EA per 31 days) QL (62.00 EA per 31 days) QL (31.00 EA per 31 days) TABS TABS, SOLN SYRP TABS, CAPS TABS TABS CAPS PA; QL (504.00 EA per 365 days) PA; QL (372.00 EA per 31 days) SOLN, KIT PA SOLN PA QL (900.00 ML per 31 days) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 3 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Monoclonal Antibodies Neuraminidase Inhibitors Nucleosides and Nucleotides Urinary Anti-infectives Product Name SYNAGIS RELENZA DISKHALER TAMIFLU acyclovir acyclovir BARACLUDE ganciclovir ribasphere ribavirin valacyclovir hcl nitrofurantoin macrocrystalline nitrofurantoin monohydrate trimethoprim uretron d/s uticap ANTINEOPLASTIC AGENTS Antineoplastic Agents ALKERAN anastrozole AVASTIN CEENU CYCLOPHOSPHAMIDE EMCYT ERIVEDGE ERWINAZE etoposide GLEEVEC HEXALEN hydroxyurea Form SOLN AEPB SUSR, CAPS TABS, CAPS SUSP TABS CAPS TABS TABS TABS CAPS CAPS TABS ATROVENT HFA dicyclomine hcl glycopyrrolate ipratropium bromide ipratropium bromide propantheline bromide 17MCG/ACT 20MG, 10MG/5ML, 10MG 2MG, 1MG 0.02% 0.06%, 0.03% 15MG AERS TABS, SOLN, CAPS TABS SOLN SOLN TABS SPRYCEL SUTENT TABLOID TARCEVA TASIGNA QL (3500.00 ML per 31 days) PA QL (62.00 EA per 31 days) CAPS TEMODAR TRELSTAR DEPOT TRELSTAR DEPOT MIXJECT TRELSTAR LA TRELSTAR LA MIXJECT TRELSTAR MIXJECT TYKERB VANDETANIB XALKORI XELODA ZELBORAF ZOLINZA REVLIMID Coverage Detail PA TABS 2MG 1MG 400MG/16ML, 100MG/4ML 40MG, 10MG, 100MG 50MG, 25MG 140MG 150MG 10000UNIT 50MG 400MG, 100MG 50MG 500MG 5MG, 25MG, 20MG, 15MG, 10MG 2.5MG 2MG 500MG 50MG 2.5MG 2MG 5MG, 25MG, 15MG, 10MG, 2.5MG 80MG, 70MG, 50MG, 20MG, 140MG, 100MG 50MG, 25MG, 12.5MG 40MG 25MG, 150MG, 100MG 200MG, 150MG 5MG, 250MG, 20MG, 180MG, 140MG, 100MG 3.75MG 3.75MG 11.25MG 11.25MG 22.5MG 250MG 300MG, 100MG 200MG, 250MG 500MG, 150MG 240MG 100MG JAKAFI letrozole LEUKERAN LYSODREN mercaptopurine methotrexate MYLERAN AUTONOMIC DRUGS Antimuscarinics/Antispasmodics Strengths 50MG/0.5ML, 100MG/ML 5MG/BLISTER 6MG/ML, 12MG/ML,75MG, 45MG, 30MG 800MG, 400MG, 200MG 200MG/5ML 1MG, 0.5MG 500MG, 250MG 200MG 200MG 500MG, 1000MG 50MG, 100MG 100MG 100MG 0.12MG/ 120MG/ 10.8MG/ 36.2MG/ 40.8MG 0.12MG/ 120MG/ 10MG/ 36MG/ 40.8MG TABS TABS SOLN CAPS TABS CAPS CAPS SOLR CAPS TABS CAPS CAPS PA PA PA PA PA PA PA PA PA PA PA PA TABS TABS TABS TABS TABS TABS TABS PA PA PA PA CAPS PA TABS CAPS TABS TABS CAPS PA PA PA PA PA CAPS SUSR SUSR SUSR SUSR SUSR TABS TABS CAPS TABS TABS CAPS PA PA PA PA PA PA PA PA PA PA PA PA PA QL (480.00 ML per 31 days) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 4 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Autonomic Drugs, Miscellaneous Product Name CHANTIX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH PAK nicotine bethanechol chloride donepezil hcl donepezil hcl odt EXELON MESTINON MESTINON TIMESPAN pilocarpine hydrochloride PROSTIGMIN pyridostigmine bromide rivastigmine tartrate carisoprodol Centrally Acting Skeletal Muscle Relaxants chlorzoxazone cyclobenzaprine hcl methocarbamol tizanidine hcl dantrolene sodium Direct-acting Skeletal Muscle Relaxants baclofen GABA-derivative Skeletal Muscle Relaxants ergoloid mesylates Sympatholytic (Adrenergic Blocking) BLOOD FORMATION,COAGULATION & THROMBOSIS Parasympathomimetic (Cholinergic) Iron Preparations Direct Factor Xa Inhibitors Heparins Platelet-Aggregation Inhibitors Platelet-reducing Agents Hematopoietic Agents Form TABS Coverage Detail QL (186.00 EA per 365 days) 1MG TABS QL (186.00 EA per 365 days) TABS QL (186.00 EA per 365 days) QL (93.00 EA per 365 days);OTCCovered w/RX; Max 3 months per year 7MG/24HR, 21MG/24HR, 14MG/24HR 5MG, 50MG, 25MG, 10MG 5MG, 10MG 5MG, 10MG 9.5MG/24HR, 4.6MG/24HR 60MG/5ML 180MG 5MG, 7.5MG 15MG 60MG 6MG, 4.5MG, 3MG, 1.5MG 350MG 500MG 5MG, 10MG 750MG, 500MG 4MG, 2MG 50MG, 25MG, 100MG 20MG, 10MG 1MG PT24 TABS TABS TBDP PT24 SYRP TBCR TABS TABS TABS CAPS TABS TABS TABS TABS TABS CAPS TABS TABS warfarin sodium fondaparinux sodium fondaparinux sodium fondaparinux sodium fondaparinux sodium XARELTO enoxaparin sodium 10MG/ 0.8MG/ 15MCG/ 106MG/ 1MG/ 6.9MG/ 1.3MG/ 30MG/ 5MG/ 6MG/ 200MG/ 10MG/ 18.2MG 200MG 150MG 25MCG/ 1MG/ 150MG 325MG, 324MG, 15MG/ML, 220MG/5ML 25MCG/ 1MG/ 150MG 25MCG/ 1MG/ 150MG 25MCG/ 1MG/ 150MG 160MG 7.5MG, 6MG, 5MG, 4MG, 3MG, 2MG, 2.5MG, 1MG, 10MG 7.5MG, 6MG, 5MG, 4MG, 3MG, 2MG, 2.5MG, 1MG, 10MG 10MG/0.8ML 2.5MG/0.5ML 5MG/0.4ML 7.5MG/0.6ML 10MG 100MG/ML, 150MG/ML enoxaparin sodium enoxaparin sodium enoxaparin sodium enoxaparin sodium cilostazol clopidogrel anagrelide hydrochloride 120MG/0.8ML, 80MG/0.8ML 40MG/0.4ML, 30MG/0.3ML 60MG/0.6ML 300MG/3ML 50MG, 100MG 75MG 1MG, 0.5MG NEUPOGEN 480MCG/1.6ML, 480MCG/0.8ML, 300MCG/ML, 300MCG/0.5ML SOLN CENTRATEX FEOSOL ferrex 150 ferrex 150 forte ferrous sulfate iferex 150 forte myferon 150 forte poly-iron 150 forte slow release iron Coumarin Derivatives Strengths 1MG, 0.5MG jantoven CAPS TABS CAPS CAPS TBEC, TABS, SOLN, ELIX CAPS CAPS CAPS TBCR QL (124.00 EA per 31 days) QL (93.00 EA per 31 days) OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx TABS TABS SOLN SOLN SOLN SOLN TABS SOLN SOLN SOLN SOLN SOLN TABS TABS CAPS QL (11.20 ML per 31 days) QL (16.00 ML per 31 days) QL (5.60 ML per 31 days) QL (8.40 ML per 31 days) QL (35.00 EA per 365 days) QL (28.00 ML per 31 days) QL (22.40 ML per 31 days) QL (8.40 ML per 31 days) QL (16.80 ML per 31 days) QL (24.00 ML per 31 days) PA UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 5 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Hemorrheologic Agents CARDIOVASCULAR DRUGS alpha-Adrenergic Blocking Agents Bile Acid Sequestrants Fibric Acid Derivatives HMG-CoA Reductase Inhibitors beta-Adrenergic Blocking Agents Product Name Strengths PROCRIT pentoxifylline er 4000UNIT/ML, 40000UNIT/ML, 3000UNIT/ML, 2000UNIT/ML, 20000UNIT/ML, 10000UNIT/ML SOLN 400MG TBCR doxazosin mesylate prazosin hcl tamsulosin hcl terazosin hcl cholestyramine cholestyramine light cholestyramine light fenofibrate fenofibrate micronized gemfibrozil 8MG, 4MG, 2MG, 1MG 5MG, 2MG, 1MG 0.4MG 5MG, 2MG, 1MG, 10MG 4GM/DOSE, 4GM 4GM 4GM/DOSE 54MG, 160MG 67MG, 200MG, 134MG 600MG TABS CAPS CAPS CAPS POWD, PACK PACK POWD TABS CAPS TABS atorvastatin calcium lovastatin pravastatin sodium 80MG, 40MG, 20MG, 10MG 40MG, 20MG, 10MG 80MG, 40MG, 20MG, 10MG 80MG, 5MG, 40MG, 20MG, 10MG 50MG, 25MG, 100MG TABS TABS TABS simvastatin atenolol atenolol/chlorthalidone bisoprolol fumarate bisoprolol fumarate/hydrochlorothiazide carvedilol labetalol hcl metoprolol succinate er metoprolol tartrate nadolol pindolol propranolol hcl propranolol hcl er propranolol/ hydrochlorothiazide sorine sotalol hcl sotalol hcl (af) timolol maleate Calcium-Channel Blocking Agents, Misc cartia xt diltiazem cd diltiazem hcl diltiazem hcl er matzim la verapamil hcl Form Coverage Detail PA QL (756.00 GM per 31 days) ST; Must fail preferred Pravastatin, Simvastatin, Lovastatin TABS TABS 50MG/ 25MG, 100MG/ 25MG 5MG, 10MG 5MG/ 6.25MG, 2.5MG/ 6.25MG, 10MG/ 6.25MG 6.25MG, 3.125MG, 25MG, 12.5MG 300MG, 200MG, 100MG, 5MG/ML 50MG, 25MG, 200MG, 100MG 50MG, 25MG, 100MG, 1MG/ML 80MG, 40MG, 20MG 5MG, 10MG 80MG, 60MG, 40MG, 20MG, 10MG, 1MG/ML 80MG, 60MG, 160MG, 120MG TABS TABS 80MG/ 25MG, 40MG/ 25MG 80MG, 240MG, 160MG, 120MG 80MG, 240MG, 160MG, 120MG 80MG, 160MG, 120MG 5MG, 20MG, 10MG 300MG, 240MG, 180MG, 120MG 300MG, 240MG, 180MG, 120MG 90MG, 60MG, 30MG, 120MG, 50MG/10ML, 25MG/5ML, 125MG/25ML, 360MG, 300MG, 240MG, 180MG 420MG, 360MG, 300MG, 240MG, 180MG, 120MG, 90MG, 60MG 420MG, 360MG, 300MG, 240MG, 180MG 80MG, 40MG, 120MG TABS TABS TABS TABS, SOLN TB24 TABS, SOLN TABS TABS TABS, SOLN CP24 TABS TABS TABS TABS CP24 CP24 TABS, SOLN, CP24 CP24, CP12 TB24 TABS UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 6 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name verapamil hcl er Dihydropyridines Class Ia Antiarrhythmics Class Ib Antiarrhythmics Class Ic Antiarrhythmics verapamil hcl sr amlodipine besylate nifediac cc nifedical xl nifedipine nifedipine er disopyramide phosphate NORPACE CR procainamide hcl quinidine gluconate quinidine gluconate cr quinidine gluconate er quinidine sulfate lidocaine hcl mexiletine hcl flecainide acetate propafenone hcl Class III Antiarrhythmics amiodarone hcl Cardiotonic Agents Central Alpha-Agonists digoxin clonidine hcl guanfacine hcl methyldopa Direct Vasodilators Angiotensin II Receptor Antagonists hydralazine hcl minoxidil losartan potassium Angiotensin-Converting Enzyme Inhibitors losartan potassium/hydrochlorothiazide benazepril hcl benazepril hcl/hydrochlorothiazide captopril captopril/hydrochlorothiazide enalapril maleate enalapril maleate/hydrochlorothiazide fosinopril sodium lisinopril lisinopril/hydrochlorothiazide quinapril hcl Mineralocorticoid (Aldost) Nitrates and Nitrites Phosphodiesterase Type 5 Inhibitors ramipril spironolactone spironolactone/ hydrochlorothiazide Strengths 240MG, 180MG, 120MG, 300MG, 200MG, 100MG 240MG, 360MG, 180MG, 120MG 5MG, 2.5MG, 10MG 90MG, 60MG, 30MG 60MG, 30MG 10MG 90MG, 60MG, 30MG 150MG, 100MG 150MG 500MG/ML, 100MG/ML 80MG/ML 324MG 324MG 300MG 20MG/ML 250MG, 200MG, 150MG 50MG, 150MG, 100MG 300MG, 225MG, 150MG 400MG, 200MG, 50MG/ML, 150MG/3ML 0.25MG, 0.125MG, 0.25MG/ML, 0.05MG/ML 0.3MG, 0.2MG, 0.1MG 2MG, 1MG 500MG, 250MG 50MG, 25MG, 10MG, 100MG, 20MG/ML 2.5MG, 10MG 50MG, 25MG, 100MG 100MG/25MG, 50MG/12.5MG, 100MG/12.5MG 5MG, 40MG, 20MG, 10MG 5MG/ 6.25MG, 20MG/ 25MG, 20MG/ 12.5MG, 10MG/ 12.5MG 50MG, 25MG, 12.5MG, 100MG Form Coverage Detail TBCR, CP24 TBCR, CP24 TABS TB24 TB24 CAPS TB24 CAPS CP12 SOLN SOLN TBCR TBCR TABS SOLN CAPS TABS TABS TABS, SOLN TABS, SOLN TABS TABS TABS TABS, SOLN TABS TABS TABS TABS QL (31.00 EA per 31 days) QL (31.00 EA per 31 days) TABS TABS 50MG/ 25MG, 50MG/ 15MG, 25MG/ 25MG, 25MG/ 15MG TABS 5MG, 20MG, 2.5MG, 10MG TABS 5MG/ 12.5MG, 10MG/ 25MG 40MG, 20MG, 10MG 5MG, 40MG, 30MG, 20MG, 2.5MG, 10MG 20MG/ 25MG, 20MG/ 12.5MG, 10MG/ 12.5MG 5MG, 40MG, 20MG, 10MG TABS TABS TABS TABS TABS 5MG, 2.5MG, 10MG, 1.25MG CAPS 50MG, 25MG, 100MG TABS isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er NITRO-BID nitroglycerin transdermal NITROSTAT ADCIRCA 25MG/ 25MG 5MG, 30MG, 20MG, 10MG, 2.5MG 40MG 20MG, 10MG 60MG, 30MG, 120MG 2% 0.6MG/HR, 0.4MG/HR, 0.2MG/HR, 0.1MG/HR 0.6MG, 0.4MG, 0.3MG 20MG TABS TABS, SUBL TBCR TABS TB24 OINT PT24 SUBL TABS PA UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 7 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name Vasodilating Agents, Miscellaneous CENTRAL NERVOUS SYSTEM AGENTS Analgesics and Antipyretics, Misc Form Coverage Detail dipyridamole LETAIRIS Strengths 75MG, 50MG, 25MG, 5MG/ML 5MG TABS, SOLN TABS PA acetaminophen 160MG/5ML SOLN acetaminophen 325MG TABS acetaminophen bupap butalbital/acetaminophen butalbital/acetaminophen/ caffeine butalbital/acetaminophen/ caffeine cephadyn mapap margesic marten-tab repan zebutal 500MG 50MG/ 650MG 50MG/ 325MG TABS TABS TABS OTC- Covered w/Rx QL (279.00 EA per 31 days);OTCCovered w/Rx QL (186.00 EA per 31 days);OTCCovered w/Rx QL (93.00 EA per 31 days) QL (186.00 EA per 31 days) 50MG/ 500MG/ 40MG TABS QL (124.00 EA per 31 days) TABS, CAPS TABS LIQD CAPS TABS TABS CAPS QL (186.00 EA per 31 days) QL (93.00 EA per 31 days) OTC-Covered w/Rx QL (186.00 EA per 31 days) QL (186.00 EA per 31 days) QL (186.00 EA per 31 days) QL (124.00 EA per 31 days) QL (31.00 EA per 31 days); ST; Must fail preferred NSAID ibuprofen indomethacin ketoprofen 50MG/ 325MG/ 40MG 50MG/ 650MG 160MG/5ML 50MG/325MG/ 40MG 50MG/ 325MG 50MG/ 325MG/ 40MG 50MG/ 500MG/ 40MG 50MG, 400MG, 200MG, 100MG 81MG, 325MG, 600MG, 300MG 81MG 50MG/ 325MG/ 40MG 50MG/ 325MG/ 40MG 81MG 750MG, 500MG, 1000MG, 500MG/5ML 750MG, 500MG 40MG/ML, 100MG/5ML 50MG 75MG, 50MG, 25MG 100MG 100MG 500MG 500MG, 400MG, 300MG, 200MG 600MG 50MG, 100MG 200MG, 100MG/5ML 800MG, 600MG, 400MG, 100MG/5ML 50MG, 25MG 75MG, 50MG ketorolac tromethamine meloxicam nabumetone naproxen naproxen naproxen dr naproxen sodium oxaprozin piroxicam sulindac tolmetin sodium acetaminophen/codeine acetaminophen/codeine #2 acetaminophen/codeine #3 acetaminophen/codeine #4 10MG 7.5MG, 15MG 750MG, 500MG 125MG/5ML 500MG, 375MG, 250MG 500MG 550MG, 275MG 600MG 20MG, 10MG 200MG, 150MG 400MG 120MG/5ML/ 12MG/5ML 300MG/ 15MG 300MG/ 30MG 300MG/ 60MG ascomp/codeine butalbital/acetaminophen/ caffeine/codeine 50MG/ 325MG/ 40MG/ 30MG CAPS Cyclooxygenase-2 (COX-2) CELEBREX Salicylates aspirin aspirin children's butalbital compound butalbital/aspirin/caffeine children's aspirin low strength Other Nonsteroidal Anti-inflammatory Agents choline magnesium trisalicylate salsalate children's ibuprofen diclofenac potassium diclofenac sodium dr diclofenac sodium er diclofenac sodium xr DIFLUNISAL etodolac fenoprofen calcium flurbiprofen ibuprofen Opiate Agonists CAPS CHEW, TABS, SUPP CHEW TABS TABS, CAPS CHEW TABS, LIQD TABS SUSP TABS TBEC TB24 TB24 TABS TABS, CAPS TABS TABS TABS, SUSP OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx TABS, SUSP CAPS CAPS TABS TABS TABS SUSP TABS TBEC TABS TABS CAPS TABS CAPS SOLN TABS TABS TABS 50MG/ 325MG/ 40MG/ 30MG CAPS QL (20.00 EA per 31 days); Maximum of a 5 day supply per Rx per month QL (2000.00 ML per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (186.00 EA per 31 days) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 8 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name butalbital/aspirin/caffeine/ codeine codeine phosphate codeine sulfate co-gesic DILAUDID-5 endocet endodan fentanyl hydrocodone bitartrate/acetaminophen hydrocodone/acetaminophen hydrocodone/acetaminophen hydrogesic hydromorphone hcl hydromorphone hcl methadone hcl methadone hcl methadose morphine sulfate morphine sulfate morphine sulfate er oxycodone hcl oxycodone hcl oxycodone/acetaminophen Opiate Partial Agonists Amphetamines oxycodone/acetaminophen oxycodone/aspirin roxicet tramadol hcl buprenorphine hcl butorphanol tartrate pentazocine/naloxone hcl SUBOXONE ADDERALL XR amphetamine/ dextroamphetamine dextroamphetamine sulfate dextroamphetamine sulfate er VYVANSE Strengths Form 50MG/ 325MG/ 40MG/ 30MG 30MG/ML, 15MG/ML 60MG, 30MG, 15MG 5MG/ 500MG 1MG/ML 7.5MG/ 500MG, 7.5MG/ 325MG, 5MG/ 325MG, 10MG/ 325MG 325MG/ 4.835MG 75MCG/HR, 50MCG/HR, 25MCG/HR, 12MCG/HR, 100MCG/HR CAPS SOLN TABS TABS LIQD 10MG/ 750MG 500MG/15ML/ 7.5MG/15ML 7.5MG/ 750MG, 7.5MG/ 650MG, 7.5MG/ 500MG, 7.5MG/ 325MG, 5MG/ 500MG, 5MG/ 325MG, 2.5MG/ 500MG, 10MG/ 660MG, 10MG/ 650MG, 10MG/ 500MG, 10MG/ 325MG 5MG/ 500MG 3MG 8MG, 4MG, 2MG 5MG/5ML, 10MG/5ML 5MG, 10MG 10MG 5MG, 30MG, 20MG, 10MG, 8MG/ML, 5MG/ML, 50MG/ML, 25MG/ML, 20MG/ML, 20MG/5ML, 1MG/ML, 15MG/ML, 10MG/ML, 10MG/5ML, 0.5MG/ML 30MG, 15MG 60MG, 30MG, 200MG, 15MG, 100MG 20MG/ML 5MG, 30MG, 20MG, 15MG, 10MG 10MG/ 650MG 10MG/ 325MG, 5MG/ 500MG, 7.5MG/ 500MG, 7.5MG/ 325MG, 5MG/ 325MG 325MG/ 4.835MG 5MG/ 325MG 50MG 8MG, 2MG 10MG/ML 0.5MG/ 50MG 8MG/ 2MG, 2MG/ 0.5MG 5MG, 10MG, 15MG, 20MG, 25MG, 30MG 5MG, 7.5MG, 10MG, 12.5MG, 15MG, 20MG, 30MG 5MG, 10MG Coverage Detail QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) TABS TABS QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) PT72 PA; QL (10.00 EA per 31 days) TABS SOLN QL (248.00 EA per 31 days) QL (3720.00 ML per 31 days) TABS CAPS SUPP TABS SOLN TABS TABS QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) SUPP, SOLN TABS QL (248.00 EA per 31 days) TB12 CONC QL (248.00 EA per 31 days) QL (248.00 ML per 31 days) TABS, CAPS TABS QL (248.00 EA per 31 days) QL (186.00 EA per 31 days) TABS, CAPS TABS TABS TABS SUBL SOLN TABS FILM QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) QL (248.00 EA per 31 days) PA QL (3.00 ML per 31 days) CP24 PA QL (62.00 EA per 31 days); AL (min: 6y; max: 20y); ST; Must fail preferred Vyvanse TABS TABS 5MG, 15MG, 10MG CP24 70MG, 60MG, 50MG, 40MG, 30MG, 20MG CAPS QL (31.00 EA per 31 days); AL (min: 6y; max: 20y); ST; Must fail preferred Vyvanse QL (31.00 EA per 31 days); AL (min: 6y; max: 20y) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 9 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Anorexigenics & Resp & Cereb Stim, Misc Anticonvulsants, Miscellaneous Barbiturates Benzodiazepines Hydantoins Succinimides Antimanic Agents Selective Serotonin Agonists Adamantanes Anticholinergic Agents Product Name dexmethylphenidate hcl METHYLIN methylphenidate hcl methylphenidate hcl er Strengths 5MG, 2.5MG, 10MG 5MG, 2.5MG, 10MG 5MG, 20MG, 10MG 20MG, 10MG Form TABS CHEW TABS TBCR methylphenidate hcl er 36MG, 27MG, 18MG TBCR methylphenidate hcl er methylphenidate hcl sr carbamazepine carbamazepine carbamazepine divalproex sodium divalproex sodium dr divalproex sodium dr divalproex sodium er divalproex sodium er epitol gabapentin gabapentin gabapentin gabapentin gabapentin GABITRIL GABITRIL lamotrigine lamotrigine levetiracetam TBCR TBCR CHEW SUSP TABS CPSP TBEC TBEC TB24 TB24 TABS CAPS CAPS CAPS SOLN TABS TABS TABS TABS, CHEW TABS SOLN levetiracetam levetiracetam oxcarbazepine oxcarbazepine oxcarbazepine oxcarbazepine 54MG 20MG 100MG 100MG/5ML 200MG 125MG 250MG, 125MG 500MG 250MG 500MG 200MG 100MG 300MG 400MG 250MG/5ML 800MG, 600MG 16MG, 12MG 4MG, 2MG 5MG, 25MG 200MG, 150MG, 100MG 100MG/ML 750MG, 500MG, 1000MG, 500MG/5ML 250MG 300MG/5ML 150MG 300MG 600MG topiramate topiramate TRILEPTAL valproic acid valproic acid zonisamide zonisamide zonisamide primidone primidone clonazepam DILANTIN DILANTIN INFATABS fosphenytoin sodium PEGANONE phenytoin phenytoin sodium phenytoin sodium extended ethosuximide ethosuximide lithium carbonate lithium carbonate er lithium citrate sumatriptan sumatriptan succinate sumatriptan succinate sumatriptan succinate refill TREXIMET amantadine hcl benztropine mesylate trihexyphenidyl hcl 100MG, 50MG, 25MG, 15MG 200MG 300MG/5ML 250MG 250MG/5ML 100MG 25MG 50MG 250MG 50MG 2MG, 1MG, 0.5MG 30MG 50MG 100MG PE/2ML 250MG 125MG/5ML 50MG/ML 300MG, 200MG, 100MG 250MG 250MG/5ML 300MG, 600MG, 150MG 450MG, 300MG 8MEQ/5ML 5MG/ACT, 20MG/ACT 6MG/0.5ML, 4MG/0.5ML 50MG, 25MG, 100MG 6MG/0.5ML, 4MG/0.5ML 500MG/ 85MG 50MG/5ML, 100MG 2MG, 1MG, 0.5MG 5MG, 2MG, 0.4MG/ML TABS, CPSP TABS SUSP CAPS SYRP, SOLN CAPS CAPS CAPS TABS TABS TABS CAPS CHEW SOLN TABS SUSP SOLN CAPS CAPS SOLN TABS, CAPS TBCR SOLN SOLN SOLN TABS SOLN TABS SYRP, CAPS TABS TABS, ELIX TABS, SOLN TABS SUSP TABS TABS TABS Coverage Detail QL (62.00 EA per 31 days) QL (62.00 EA per 31 days); AL (min: 6y; max: 20y) QL (31.00 EA per 31 days); AL (min: 6y; max: 20y) QL (310.00 EA per 31 days) QL (2500.00 ML per 31 days) QL (248.00 EA per 31 days) QL (310.00 EA per 31 days) QL (310.00 EA per 31 days) QL (261.00 EA per 31 days) QL (310.00 EA per 31 days) QL (261.00 EA per 31 days) QL (248.00 EA per 31 days) QL (310.00 EA per 31 days) QL (372.00 EA per 31 days) QL (279.00 EA per 31 days) QL (2500.00 ML per 31 days) QL (310.00 EA per 31 days) QL (310.00 EA per 31 days) QL (4500.00 ML per 31 days) QL (372.00 EA per 31 days) QL (1500.00 per 31 days) QL (310.00 EA per 31 days) QL (248.00 EA per 31 days) QL (310.00 EA per 31 days) QL (248.00 EA per 31 days) QL (1500.00 ML per 31 days) QL (310.00 EA per 31 days) QL (2600.00 ML per 31 days) QL (310.00 EA per 31 days) QL (372.00 EA per 31 days) QL (248.00 EA per 31 days) QL (310.00 EA per 31 days) QL (310.00 EA per 31 days) QL (372.00 EA per 31 days) QL (372.00 EA per 31 days) QL (900.00 ML per 31 days) QL (1000.00 ML per 31 days) QL (12.00 EA per 31 days) QL (9.00 ML per 31 days) QL (9.00 EA per 31 days) QL (9.00 ML per 31 days) PA UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 10 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name Dopamine Precursors carbidopa/levodopa carbidopa/levodopa cr carbidopa/levodopa er Ergot-derivative Dopamine Receptor Agonists Nonergot-derivative Dopamine Receptor Agonists Monoamine Oxidase B Inhibitors Anxiolytics, Sedatives, & Hypnotics Misc carbidopa/levodopa sr bromocriptine mesylate pramipexole dihydrochloride ropinirole hcl selegiline hcl buspirone hcl hydroxyzine hcl hydroxyzine hcl hydroxyzine pamoate meprobamate zolpidem tartrate phenobarbital phenobarbital phenobarbital Barbiturates 5MG, 10MG 20MG/5ML 15MG 16.2MG 97.2MG, 64.8MG, 60MG, 32.4MG, 30MG, 100MG 65MG/ML, 130MG/ML phenobarbital phenobarbital sodium Benzodiazepines Central Nervous System Agents, Misc Fibromyalgia Agents Opiate Antagonists Monoamine Oxidase Inhibitors Selective Serotonin- and Norepinephrinereuptake Inhibitors Selective Serotonin-reuptake Inhibitors alprazolam chlordiazepoxide hcl clorazepate dipotassium diazepam diazepam estazolam lorazepam lorazepam oxazepam temazepam triazolam CAMPRAL NAMENDA NAMENDA TITRATION PAK SAVELLA SAVELLA TITRATION PACK naltrexone hcl phenelzine sulfate tranylcypromine sulfate venlafaxine hcl VENLAFAXINE HCL ER venlafaxine hcl er citalopram hydrobromide fluoxetine hcl paroxetine hcl PAXIL sertraline hcl Serotonin Modulators Tricyclics and Other Norepinephrine-reuptake Inhibitors nefazodone hcl trazodone hcl amitriptyline hcl Strengths 25MG/ 250MG, 25MG/ 100MG, 10MG/ 100MG 25MG/ 100MG 50MG/ 200MG, 25MG/ 100MG 50MG/ 200MG, 25MG/ 100MG 2.5MG, 5MG 1MG, 1.5MG, 0.75MG, 0.5MG, 0.25MG, 0.125MG 5MG, 4MG, 3MG, 2MG, 1MG, 0.5MG, 0.25MG 5MG 7.5MG, 5MG, 30MG, 15MG, 10MG 10MG/5ML 50MG, 25MG, 10MG 50MG, 25MG, 100MG 400MG, 200MG 2MG, 1MG, 0.5MG, 0.25MG 5MG, 25MG, 10MG 7.5MG, 3.75MG, 15MG 20MG, 2.5MG, 10MG 5MG, 2MG, 10MG, 5MG/ML, 1MG/ML 2MG, 1MG 2MG, 1MG, 0.5MG 4MG/ML, 2MG/ML 30MG, 15MG, 10MG 30MG, 15MG 0.25MG, 0.125MG 333MG 5MG, 10MG, 10MG/5ML 50MG, 25MG, 12.5MG, 100MG 50MG 15MG 10MG 75MG, 50MG, 37.5MG, 25MG, 100MG 225MG 75MG, 37.5MG, 150MG 40MG, 20MG, 10MG, 10MG/5ML 20MG, 10MG, 40MG, 20MG/5ML 40MG, 30MG, 20MG, 10MG 10MG/5ML 50MG, 25MG, 100MG, 20MG/ML 50MG, 250MG, 200MG, 150MG, 100MG 50MG, 150MG, 100MG 75MG, 50MG, 25MG, 150MG, 10MG, 100MG Form Coverage Detail TABS TBCR TBCR TBCR TABS, CAPS TABS ST; Must fail preferred Ropinirole TABS TABS, CAPS TABS SYRP, SOLN TABS CAPS TABS TABS ELIX TABS TABS QL (450.00 ML per 31 days) AL (min: 18y); QL (31.00 EA per 31 days) QL (2000.00 ML per 31 days) QL (310.00 EA per 31 days) QL (383.00 EA per 31 days) TABS SOLN TABS CAPS TABS KIT TABS, SOLN TABS TABS SYRINGE CAPS CAPS TABS TBEC TABS, SOLN TABS AL (min: 9y) QL (3.00 EA per 31 days) AL (min: 18y) QL (186.00 EA per 31 days) TABS MISC TABS TABS TABS TABS TB24 TB24, CP24 QL (31.00 EA per 31 days) QL (31.00 EA per 31 days) TABS, SOLN TABS, CAPS, SOLN TABS SUSP TABS, CONC TABS TABS TABS UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 11 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name Strengths 50MG, 25MG, 150MG, 100MG AMOXAPINE chlordiazepoxide /amitriptyline clomipramine hcl desipramine hcl doxepin hcl imipramine hcl maprotiline hcl nortriptyline hcl Miscellaneous Antidepressants perphenazine/ amitriptyline protriptyline hcl budeprion sr budeprion xl bupropion hcl bupropion hcl sr bupropion hcl xl mirtazapine mirtazapine odt Atypical Antipsychotics clozapine quetiapine fumarate risperidone CONC, CAPS TABS TABS CAPS TABS TABS TB12 TB24 TABS TB12 TB24 TABS, CONC SOLN SOLN chlorpromazine hcl fluphenazine decanoate fluphenazine hcl fluphenazine hcl fluphenazine hcl perphenazine prochlorperazine prochlorperazine maleate thioridazine hcl trifluoperazine hcl thiothixene loxapine succinate ORAP 50MG, 25MG, 10MG, 100MG 5MG, 2MG, 1MG, 10MG 5MG, 2MG, 1MG, 10MG 5MG, 50MG, 25MG, 10MG 2MG, 1MG TABS TABS CAPS CAPS TABS risperidone m-tab risperidone odt HALDOL DECANOATE 50 haloperidol haloperidol decanoate haloperidol lactate Thioxanthenes Miscellaneous Antipsychotics TABS 1MG/ML 4MG, 3MG, 2MG, 1MG, 0.5MG, 0.25MG 4MG, 3MG, 2MG, 1MG, 0.5MG 0.5MG, 0.25MG, 4MG, 3MG, 2MG, 1MG 50MG/ML 5MG, 2MG, 1MG, 10MG, 0.5MG, 2MG/ML 50MG/ML, 100MG/ML 5MG/ML 50MG, 25MG, 200MG, 10MG, 100MG 25MG/ML 5MG/ML 2.5MG/5ML 5MG, 2.5MG, 1MG, 10MG 8MG, 4MG, 2MG, 16MG 25MG 5MG, 10MG risperidone Phenothiazines TABS CAPS 12.5MG TBDP 7.5MG, 5MG, 20MG, 2.5MG, 15MG, 10MG TABS 50MG, 400MG, 300MG, 25MG, 200MG, 100MG TABS olanzapine Coverage Detail TABS 15MG, 7.5MG, 45MG, 30MG TBDP, TABS 45MG, 30MG TBDP 50MG, 25MG, 200MG, 100MG TABS FAZACLO Butyrophenones 5MG/ 12.5MG, 10MG/ 25MG 75MG, 50MG, 25MG 75MG, 50MG, 25MG, 150MG, 10MG, 100MG 10MG/ML, 75MG, 50MG, 25MG, 10MG, 100MG 50MG, 25MG, 10MG 75MG, 50MG, 25MG 75MG, 50MG, 25MG, 10MG 4MG/ 50MG, 4MG/ 25MG, 4MG/ 10MG, 2MG/ 25MG, 2MG/ 10MG 5MG, 10MG 150MG, 100MG 300MG 75MG, 100MG 200MG, 150MG, 100MG 300MG, 150MG Form SOLN TABS, SOLN TBDP TBDP SOLN TABS SOLN CONC ELIX TABS TABS SUPP TABS AL (min: 10y) AL (min: 10y); QL (31.00 EA per 31 days) AL (min: 5y, max: 999y); QL (62.00 ML per 31 days) AL (min: 5y, max: 999y); QL (62.00 EA per 31 days) AL (min: 5y, max: 999y); QL (62.00 EA per 31 days) AL (min: 5y, max: 999y); QL (62.00 EA per 31 days) QL (250.00 ML per 31 days) QL (2500.00 ML per 31 days) DEVICES Devices ACCU-CHEK ACTIVE CARE KIT ACCU-CHEK ACTIVE GLUCOSE CONTROL SOLUTION KIT QL (2.00 EA per 365 days);OTCCovered w/Rx LIQD OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 12 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name ACCU-CHEK ADVANTAGE DIABETES CARE KIT ACCU-CHEK AVIVA Strengths ACCU-CHEK AVIVA PLUS ACCU-CHEK COMFORT CURVE CONTROL SOLUTION (2 LEVELS) ACCU-CHEK COMPACT BLUE CONTROL SOLUTION (2 LEVELS) ACCU-CHEK COMPACT PLUS CARE KIT ACCU-CHEK MULTICLIX LANCET DEVICE KIT ACCU-CHEK NANO SMARTVIEW ACCU-CHEK SMARTVIEW CONTROL ACCU-CHEK SOFTCLIX LANCET DEVICE ACCU-CHEK SOFTCLIX LANCET DEVICE KIT AEROCHAMBER PLUS AEROCHAMBER PLUS/LARGE MASK AEROCHAMBER PLUS/MASK AEROCHAMBER PLUS/SMALL MASK ALCOHOL SWABS E-Z SPACER FREESTYLE CONTROL SOLUTION FREESTYLE FREEDOM LITE FREESTYLE LITE BLOOD GLUCOSE MONITORING SYSTEM Form KIT Coverage Detail QL (2.00 EA per 365 days);OTCCovered w/Rx OTC-Covered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx SOLN OTC-Covered w/Rx LIQD OTC-Covered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx KIT SOLN KIT KIT KIT OTC-Covered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx LIQD OTC-Covered w/Rx MISC OTC-Covered w/Rx KIT MISC OTC-Covered w/Rx QL (2.00 EA per 365 days) MISC QL (2.00 EA per 365 days) MISC QL (2.00 EA per 365 days) MISC PADS DEVI QL (2.00 EA per 365 days) OTC-Covered w/Rx QL (2.00 EA per 365 days) LIQD KIT OTC-Covered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx DEVI QL (2.00 EA per 365 days);OTCCovered w/Rx IN-CHECK DIAL INSPIRATORY FLOW TRAINER DEVI INSULIN SYRINGES MISC LANCETS MEDISENSE HIGH/MID/LOW CONTROL SOLUTION MICROCHAMBER MICROSPACER NOVOPEN 3 INSULIN DELIVERY SYSTEM OPTICHAMBER ADVANTAGE OPTICHAMBER ADVANTAGE/LARGE MASK OPTICHAMBER ADVANTAGE/MEDIUM FACE MASK OPTICHAMBER ADVANTAGE/SMALL FACE MASK OPTICHAMBER FACE MASK/LARGE MISC QL (2.00 EA per 365 days) QL (100.00 per 31 days); OTC-Covered w/Rx Accu-Chek Multiclix lancets: QL (204.00 per 31 days); OTC Covered w/Rx All other lancets: QL (200.00 per 31 days);OTC Covered w/Rx LIQD MISC MISC OTC-Covered w/Rx QL (2.00 EA per 365 days) QL (2.00 EA per 365 days) MISC MISC QL (2.00 EA per 365 days) MISC QL (2.00 EA per 365 days) MISC QL (2.00 EA per 365 days) MISC QL (2.00 EA per 365 days) QL (2.00 EA per 365 days);OTCCovered w/Rx MISC UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 13 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name Strengths OPTICHAMBER FACE MASK/MEDIUM OPTICHAMBER FACE MASK/SMALL OPTIHALER PEAK AIR PEAK FLOW METER ADULT/PEDIATRIC Form MISC MISC MISC DEVI Coverage Detail QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days) QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx OTC-Covered w/Rx PEAK FLOW METER PEN NEEDLES PERSONAL BEST FULL RANGE DEVI MISC PERSONAL BEST LOW RANGE DEVI POCKET PEAK FLOW METER POCKETPEAK PEAK FLOW METER LOW RANGE POCKETPEAK PEAK FLOW METER/UNIVERSAL RANGE DEVI PRECISION XTRA DEVI QL (2.00 EA per 365 days) QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx QL (2.00 EA per 365 days);OTCCovered w/Rx TRUZONE PEAK FLOW METER DEVI QL (2.00 EA per 365 days) DEVI DEVI DEVI DIAGNOSTIC AGENTS Diabetes Mellitus ACCU-CHEK ACTIVE STRIPS STRP ACCU-CHEK AVIVA PLUS STRP ACCU-CHEK COMFORT CURVE TEST STRIPS STRP ACCU-CHEK COMPACT STRIPS STRP ACCU-CHEK COMPACT TEST DRUM STRP ACCU-CHEK SMARTVIEW STRIPS STRP FREESTYLE LITE TEST STRIPS STRP FREESTYLE TEST STRIPS STRP OTC-Covered w/RX QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old OTC- Covered w/RX QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old OTC-Covered w/RX QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old OTC- Covered w/RX QL: 204/31 DS for Members 21 years old and younger; QL:102/31 DS for Members over 21 years old OTC- Covered w/RX QL: 204/31 DS for Members 21 years old and younger; QL:102/31 DS for Members over 21 years old OTC-Covered w/ Rx QL: 200/31 DS for Members 21 years old and younger QL: 100/31 DS for Members over 21 years old OTC- Covered w/RX QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old OTC- Covered w/RX QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 14 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name Strengths Form STRP Coverage Detail OTC- Covered w/RX QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old QL (100.00 EA per 31 days);OTCCovered w/Rx QL (100.00 EA per 31 days);OTCCovered w/Rx QL (100.00 EA per 31 days);OTCCovered w/Rx SOLN QL (3600.00 ML per 31 days) SYRP GRAN SOLN SOLN SOLN QL (3600.00 ML per 31 days) OTC-Covered w/Rx QL (2000.00 ML per 31 days) QL (2000.00 ML per 31 days) QL (2000.00 ML per 31 days) PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP Ketones KETOSTIX STRP Sugar CLINISTIX STRP DIASTIX ELECTROLYTIC, CALORIC, AND WATER BALANCE cytra-2 Alkalinizing Agents 334MG/5ML/ 500MG/5ML 334MG/5ML/ 550MG/5ML/ 500MG/5ML Ammonia Detoxicants cytra-3 sodium citrate enulose generlac lactulose Loop Diuretics bumetanide Potassium-sparing Diuretics furosemide torsemide amiloride/hydrochlorothiazide Thiazide Diuretics Thiazide-like Diuretics Phosphate-removing Agents Potassium-removing Agents Irrigating Solutions Replacement Preparations triamterene/hydrochlorothiazide chlorothiazide hydrochlorothiazide chlorthalidone indapamide metolazone RENVELA kionex sodium polystyrene sulfonate sps curity sterile saline sodium chloride calcium acetate calcium carbonate calcium carbonate/vitamin d calcium lactate CAL-LAC ELIPHOS klor-con klor-con 10 klor-con 8 klor-con m10 klor-con m20 magnesium magnesium oxide NEUTRA-PHOS normal saline flush oralyte oralyte freezer pops potassium chloride potassium chloride cr potassium chloride er potassium chloride sr 10GM/15ML 10GM/15ML 10GM/15ML 2MG, 1MG, 0.5MG, 0.25MG/ML 80MG, 40MG, 20MG, 8MG/ML, 10MG/ML 5MG, 20MG, 10MG, 100MG 5MG/ 50MG 75MG/ 50MG, 37.5MG/ 25MG 500MG, 250MG 50MG, 25MG, 12.5MG 50MG, 25MG 2.5MG, 1.25MG 5MG, 2.5MG, 10MG 800MG, 2.4GM, 0.8GM 15GM/60ML 0.9% 0.9% 667MG 600MG, 1500MG, 1250MG, 1250MG/5ML 600MG/ 400UNIT 650MG 500MG 667MG 20MEQ 10MEQ 8MEQ 10MEQ 20MEQ 500MG 420MG, 400MG, 250MG 250MG/75ML/ 278MG/75ML/ 164MG/75ML 0.9% 35MEQ/L/ 25GM/L/ 20MEQ/L/ 45MEQ/L/ 7.8MG/L 35MEQ/L/ 25GM/L/ 20MEQ/L/ 45MEQ/L 40MEQ/100ML, 30MEQ/100ML, 2MEQ/ML, 10MEQ/100ML, 10%, 0.4MEQ/ML, 20% 10MEQ 8MEQ, 20MEQ, 10MEQ 8MEQ TABS, SOLN TABS, SOLN TABS TABS TABS, CAPS TABS TABS, CAPS TABS TABS TABS TABS, PACK POWD POWD SUSP SOLN SOLN TABS QL (454.00 GM per 31 days) QL (454.00 GM per 31 days) QL (1000.00 ML per 31 days) QL (372.00 EA per 31 days) TABS, SUSP TABS TABS CAPS TABS PACK TBCR TBCR TBCR TBCR TABS TABS OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx QL (372.00 EA per 31 days) SOLR SOLN OTC-Covered w/Rx QL (310.00 ML per 31 days) SOLN SOLN OTC-Covered w/Rx OTC-Covered w/Rx QL (4000.00 ML per 31 days);OTCCovered w/Rx QL (4000.00 ML per 31 days);OTCCovered w/Rx SOLN, LIQD TBCR TBCR, CPCR TBCR UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 15 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name saline flush sodium chloride sodium chloride zinc sulfate probenecid Uricosuric Agents ENZYMES LUMIZYME Enzymes EYE, EAR, NOSE & THROAT PREPARATIONS alaway Antiallergic Agents azelastine hcl cromolyn sodium cromolyn sodium ketotifen fumarate ALPHAGAN P alpha-Adrenergic Agonists brimonidine tartrate betaxolol hcl beta-Adrenergic Blocking Agents BETOPTIC-S carteolol hcl levobunolol hcl metipranolol timolol maleate timolol maleate ophthalmic gel forming acetazolamide Carbonic Anhydrase Inhibitors AZOPT dorzolamide hcl Prostaglandin Analogs dorzolamide hcl/timolol maleate methazolamide latanoprost Antibacterials ak-poly-bac bacitracin/polymyxin b ciprofloxacin hcl opth erythromycin gentamicin sulfate neomycin/bacitracin/polymyxin neomycin/polymyxin/gramicidin ofloxacin otic ofloxacin opth Antivirals EENT Anti-infectives, Miscellaneous Corticosteroids polycin b polymyxin b sulfate/trimethoprim sulfate sulfacetamide sodium tobramycin sulfate trifluridine chlorhexidine gluconate oral rinse periogard CIPRODEX dexamethasone sodium phosphate flunisolide fluorometholone fluor-op fluticasone propionate FML FORTE LOTEMAX MAXIDEX Strengths 0.9% 0.9% 0.9% 220MG 500MG Form SOLN SYRINGE VIAL TABS TABS Coverage Detail QL (310.00 ML per 31 days) QL (310.00 ML per 31 days) 50MG SOLR PA 0.025% 137MCG/SPRAY 5.2MG/ACT 4% 0.025% 0.1% 0.2% 0.5% 0.25% 1% 0.5%, 0.25% 0.3% 0.5%, 0.25% SOLN SOLN AERS SOLN SOLN SOLN SOLN SOLN SUSP SOLN SOLN SOLN SOLN OTC-Covered w/Rx 0.5%, 0.25% 250MG, 125MG 1% 2% SOLG TABS SUSP SOLN 22.3MG/ML/ 6.8MG/ML 50MG, 25MG 0.005% 500UNIT/GM/ 10000UNIT/GM 500UNIT/GM/ 10000UNIT/GM 0.3% 5MG/GM 0.3% 400UNIT/GM/ 5MG/GM/ 10000UNIT/GM 0.025MG/ML/ 1.75MG/ML/ 10000UNIT/ML 0.3% 0.3% 500UNIT/GM/ 10000UNIT/GM SOLN TABS SOLN OTC-Covered w/Rx OTC-Covered w/Rx QL (5.00 ML per 31 days) OINT OINT SOLN OINT SOLN OINT SOLN SOLN SOLN OINT 10000UNIT/ML/ 0.1% 10% 0.3% 1% SOLN SOLN SOLN SOLN 0.12% 0.12% SOLN SOLN 0.3%/ 0.1% SUSP 0.1% 29MCG/ACT, 0.025% 0.1% 0.1% 50MCG/ACT 0.25% 0.5% 0.1% SOLN SOLN SUSP SUSP SUSP SUSP SUSP SUSP QL (480.00 ML per 31 days) QL (480.00 ML per 31 days) ST; AL (max: 8y);Preferred for members 8 years old and younger; Members 9 years old and older: Covered w/step edit: Trial and Failure of Ofloxacin 0.3% ear drops UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 16 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name neomycin/polymyxin/ dexamethasone neomycin/polymyxin/ hydrocortisone EENT Anti-inflammatory Agents, Misc Nonsteroidal Anti-inflammatory Agents EENT Drugs, Miscellaneous Local Anesthetics Mydriatics Vasoconstrictors GASTROINTESTINAL DRUGS Antacids and Adsorbents Antidiarrhea Agents 5-HT3 Receptor Antagonists Antihistamines Anti-inflammatory Agents Histamine H2-Antagonists Prostaglandins Protectants Proton-pump Inhibitors Cathartics and Laxatives poly-dex PRED-G prednisolone acetate sulfacetamide sodium/prednisolone sodium phosphate TOBRADEX VEXOL RESTASIS diclofenac sodium flurbiprofen sodium acetic acid/aluminum acetate artificial tears antipyrine/benzocaine lidocaine viscous oticin atropine sulfate ISOPTO HYOSCINE AK-CON aluminum hydroxide calcium carbonate Strengths 0.1%/ 3.5MG/ML/ 10000UNIT/ML, 0.1%/ 3.5MG/GM/ 10000UNIT/GM 1%/ 3.5MG/ML/ 10000UNIT/ML 0.1%/ 3.5MG/GM/ 10000UNIT/GM 0.3%/ 1% 1% 0.23%/ 10% 0.1%/ 0.3% 1% 0.05% 0.1% 0.03% 2% 1.4% 54MG/ML/ 14MG/ML, 5.4%/ 1.4% 2% 1MG/ML/ 10MG/ML 1% 0.25% 0.1% Form SUSP, OINT SUSP, SOLN OINT SUSP SUSP SOLN OINT SUSP EMUL SOLN SOLN SOLN SOLN cimetidine cimetidine hcl famotidine famotidine famotidine premixed ranitidine 75 ranitidine acid reducer ranitidine hcl 50MG/2ML, 25MG/ML, 150MG/6ML, 300MG, 150MG SOLN, CAPS, TABS ranitidine hcl misoprostol CARAFATE sucralfate omeprazole pantoprazole sodium docusate calcium docusate sodium gavilyte-g 15MG/ML 200MCG, 100MCG 1GM/10ML 1GM 40MG, 20MG, 10MG 40MG, 20MG 240MG 100MG, 250MG, 100MG 236GM/ 2.97GM/ 6.74GM/ 5.86GM/ 22.74GM QL (15.00 ML per 31 days) SOLN SOLN LIQD SOLN, OINT SOLN SOLN 320MG/5ML 500MG 0.025MG/ 2.5MG, 0.025MG/5ML/ 2.5MG/5ML 0.025MG/ 2.5MG 2MG 8MG, 4MG, 4MG/5ML 24MG 8MG, 4MG 12.5MG, 25MG 12.5MG, 25MG 25MG 25MG 0.375GM 750MG 4GM 75MG 200MG 800MG, 400MG, 300MG, 200MG 300MG/5ML, 150MG/ML 10MG 40MG, 20MG, 10MG/ML 0.4MG/ML/ 0.9% 75MG 75MG diphenoxylate/atropine lonox loperamide hcl ondansetron hcl ondansetron hcl ondansetron odt meclizine hcl meclizine hcl medi-meclizine travel sickness APRISO balsalazide disodium mesalamine acid reducer cimetidine Coverage Detail SUSP CHEW TABS, LIQD TABS CAPS TABS, SOLN TABS TBDP TABS TABS TABS CHEW CP24 CAPS ENEM TABS TABS TABS SOLN TABS TABS, SOLN SOLN TABS TABS OTC-Covered w/Rx OTC-Covered w/Rx QL (31.00 EA per 31 days) OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx QL (1800.00 ML per 31 days) OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx AL (max: 5y); QL (600.00 ML per 31 days) SYRP TABS SUSP TABS CPDR TBEC CAPS TABS, CAPS OTC-Covered w/Rx OTC-Covered w/Rx SOLR QL (4000.00 ML per 31 days) QL (1200.00 ML per 31 days) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 17 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name gavilyte-n/flavor pack GOLYTELY PACKET METAMUCIL metamucil smooth texture peg 3350/electrolytes peg-3350/nacl/na bicarbonate/kcl polyethylene glycol 3350 sorbitol Cholelitholytic Agents Digestants Prokinetic Agents Strengths 420GM/ 1.48GM/ 5.72GM/ 11.2GM 227.1GM/ 2.82GM/ 6.36GM/ 5.53GM/ 21.5GM 0.52GM 28.3% 240GM/ 2.98GM/ 6.72GM/ 5.84GM/ 22.72GM, 236GM/ 2.97GM/ 6.74GM/ 5.86GM/ 22.74GM 420GM/ 1.48GM/ 5.72GM/ 11.2GM Form Coverage Detail SOLR QL (4000.00 ML per 31 days) SOLR WAFR, CAPS POWD QL (1.00 EA per 31 days) OTC-Covered w/Rx OTC-Covered w/Rx SOLR QL (4000.00 ML per 31 days) SOLR POWD SOLN QL (4000.00 ML per 31 days) QL (527.00 GM per 31 days) OTC-Covered w/Rx SOLR CAPS QL (4000.00 ML per 31 days) 70% 420GM/ 1.48GM/ 5.72GM/ 11.2GM 300MG 82000UNIT/ 15000UNIT/ 51000UNIT, 55000UNIT/ 10000UNIT/ 34000UNIT, 27000UNIT/ 5000UNIT/ 17000UNIT, 16000UNIT/ 3000UNIT/ 10000UNIT, 136000UNIT/ 25000UNIT/ 85000UNIT, 109000UNIT/ 20000UNIT/ 68000UNIT 5MG/5ML 5MG, 10MG CPEP SOLN TABS 3MG CAPS 500MG, 2GM SOLR 40MG, 125MG SOLR 220MCG/INH AEPB 220MCG/INH AEPB 220MCG/INH, 110MCG/INH AEPB 220MCG/INH AEPB ASMANEX 7 METERED DOSES 110MCG/INH AEPB budesonide CELESTONE cortisone acetate SUSP SOLN TABS trilyte ursodiol ZENPEP metoclopramide hcl metoclopramide hcl GOLD COMPOUNDS RIDAURA Gold Compounds HEAVY METAL ANTAGONISTS deferoxamine mesylate Heavy Metal Antagonists HORMONES AND SYNTHETIC SUBSTITUTES a-methapred Adrenals ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES dexamethasone dexamethasone sodium phosphate 0.5MG/2ML, 0.25MG/2ML 0.6MG/5ML 25MG 6MG, 4MG, 2MG, 1MG, 1.5MG, 0.75MG, 0.5MG, 0.5MG/5ML FLOVENT DISKUS 4MG/ML, 10MG/ML 50MCG/BLIST, 250MCG/BLIST, 100MCG/BLIST FLOVENT HFA fludrocortisone acetate hydrocortisone methylprednisolone methylprednisolone acetate methylprednisolone dose pack methylprednisolone sodium succinate prednisolone 44MCG/ACT, 220MCG/ACT, 110MCG/ACT 0.1MG 5MG, 20MG, 10MG 8MG, 32MG, 16MG 80MG/ML, 40MG/ML 4MG 40MG, 1GM, 125MG, 1000MG 15MG/5ML QL (1500.00 ML per 31 days) AL (max: 8y); QL (120.00 ML per 31 days) TABS, SOLN, ELIX SOLN AEPB AERO TABS TABS TABS SUSP TABS SOLR SOLN UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 18 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name prednisolone sodium phosphate prednisone Androgens Alpha-Glucosidase Inhibitors Biguanides Dipeptidyl Peptidase-4 (DPP-4) PULMICORT QVAR danazol METHITEST oxandrolone TESTIM testosterone cypionate testosterone enanthate acarbose metformin hcl metformin hcl er RIOMET Coverage Detail SOLN TABS, SOLN AL (max: 8y); QL (120.00 ML per 31 days) SUSP AERS CAPS TABS TABS GEL OIL OIL TABS TABS TB24 SOLN 50MG, 25MG, 100MG 40MG/ 100MG, 20MG/ 100MG, 10MG/ 100MG 100UNIT/ML 100UNIT/ML 50UNIT/ML/ 50UNIT/ML TABS TABS SOLN SOLN SUSP QL (900.00 ML per 31 days) ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) HUMALOG MIX 50/50 KWIKPEN 50UNIT/ML/ 50UNIT/ML HUMALOG MIX 75/25 25UNIT/ML/ 75UNIT/ML SUSP SUSP QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) HUMALOG MIX 75/25 KWIKPEN 25UNIT/ML/ 75UNIT/ML SUSP HUMULIN 70/30 30UNIT/ML/ 70UNIT/ML SUSP HUMULIN 70/30 PEN 30UNIT/ML/ 70UNIT/ML SUSP HUMULIN N 100UNIT/ML SUSP HUMULIN N U-100 PEN 100UNIT/ML SUSP HUMULIN R HUMULIN R U-500 (CONCENTRATED) LEVEMIR LEVEMIR FLEXPEN 100UNIT/ML SOLN QL (60.00 ML per 31 days) QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days);OTCCovered w/Rx 500UNIT/ML 100UNIT/ML 100UNIT/ML SOLN SOLN SOLN NOVOLIN 70/30 30UNIT/ML/ 70UNIT/ML SUSP NOVOLIN N 100UNIT/ML SUSP NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILLED FLEXPEN NOVOLOG PENFILL 100UNIT/ML 100UNIT/ML 100UNIT/ML 30UNIT/ML/ 70UNIT/ML SOLN SOLN SOLN SUSP 30UNIT/ML/ 70UNIT/ML 100UNIT/ML SUSP SOLN RELION HUMULIN 30%/ 70% SUSP RELION HUMULIN R U-100 100UNIT/ML SUSP PRANDIMET 2MG/ 500MG, 1MG/ 500MG TABS PRANDIN 2MG, 1MG, 0.5MG TABS JANUMET JANUVIA Meglitinides Form 1MG/2ML 80MCG/ACT, 40MCG/ACT 50MG, 200MG, 100MG 10MG 2.5MG, 10MG 1% 200MG/ML, 100MG/ML 200MG/ML 50MG, 25MG, 100MG 850MG, 500MG, 1000MG 750MG, 500MG 500MG/5ML 50MG/ 500MG, 50MG/ 1000MG 50MG/ 500MG, 50MG/ 1000MG, 1000MG/ 100MG JANUMET XR Insulins Strengths 6.7MG/5ML, 5MG/5ML, 15MG/5ML 5MG, 20MG, 2.5MG, 1MG, 10MG, 5MG/5ML JUVISYNC HUMALOG HUMALOG KWIKPEN HUMALOG MIX 50/50 TABS TB24 PA PA QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days);OTCCovered w/Rx QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 ML per 31 days) QL (60.00 per 31 days);OTC-Covered w/Rx QL (60.00 per 31 days);OTC-Covered w/Rx ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 19 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Sulfonylureas Product Name chlorpropamide glimepiride glipizide glipizide er glipizide xl glipizide/metformin hcl glyburide glyburide micronized glyburide/metformin hcl Thiazolidinediones ACTOPLUS MET ACTOS Antihypoglycemic Agents, Miscellaneous Glycogenolytic Agents Contraceptives Strengths 250MG, 100MG 4MG, 2MG, 1MG 5MG, 10MG 5MG, 2.5MG, 10MG 5MG, 2.5MG, 10MG 5MG/ 500MG, 2.5MG/ 500MG, 2.5MG/ 250MG 5MG, 2.5MG, 1.25MG 6MG, 3MG, 1.5MG 5MG/ 500MG, 2.5MG/ 500MG, 1.25MG/ 250MG 15MG/ 850MG, 15MG/ 500MG Form TABS TABS TABS TB24 TB24 TABS TABS TABS TABS TABS AVANDAMET 45MG, 30MG, 15MG TABS 4MG/ 500MG, 2MG/ 500MG, 4MG/ 1000MG, 2MG/ 1000MG TABS AVANDARYL 8MG/4MG, 4MG/ 4MG, 8MG/ 2MG, 4MG/ 2MG, 4MG/ 1MG TABS AVANDIA GLUCOSE GLUCAGEN GLUCAGEN HYPOKIT 8MG, 4MG, 2MG 4GM 1MG 1MG TABS CHEW SOLR SOLR GLUCAGON EMERGENCY KIT altavera apri aviane balziva briellyn camila caziant cryselle-28 emoquette enpresse-28 errin gianvi jolivette junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 kariva kelnor 1/35 lessina-28 levonorgestrel levora 0.15/30-28 loryna low-ogestrel lutera microgestin 1.5/30 microgestin 1/20 microgestin fe microgestin fe 1.5/30 mononessa necon 0.5/35-28 necon 1/35-28 necon 1/50-28 necon 7/7/7 next choice nora-be nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) 1MG 0.03MG/ 0.15MG 0.15MG/ 30MCG 20MCG/ 0.1MG 35MCG/ 0.4MG 35MCG/ 0.4MG 0.35MG KIT TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS 30MCG/ 0.3MG 0.15MG/ 30MCG 0.35MG 3MG/ 0.02MG 0.35MG 30MCG/ 1.5MG 20MCG/ 1MG 30MCG/ 75MG/ 1.5MG 20MCG/ 75MG/ 1MG 35MCG/ 1MG 20MCG/ 0.1MG 0.75MG 30MCG/ 0.15MG 3MG/ 0.02MG 30MCG/ 0.3MG 20MCG/ 0.1MG 30MCG/ 1.5MG 20MCG/ 1MG 20MCG/ 75MG/ 1MG 30MCG/ 75MG/ 1.5MG 35MCG/ 0.25MG 35MCG/ 0.5MG 35MCG/ 1MG 50MCG/ 1MG 0.75MG 0.35MG 35MCG/ 0.5MG 35MCG/ 1MG 35MCG/ 1MG Coverage Detail ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet ST; Must fail preferred Metformin, Metformin ER, Riomet OTC-Covered w/Rx QL (2.00 EA per 31 days) QL (2.00 EA per 31 days) QL (2.00 EA per 31 days) QL (4.00 EA per 31 days) QL (4.00 EA per 31 days) UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 20 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name nortrel 7/7/7 Estrogen Agonist-Antagonists Strengths 0.015MG/24HR/ 0.12MG/24HR 3MG/ 0.03MG 0.03MG/ 0.15MG 35MCG/ 0.25MG 0.03MG/ 0.15MG 0.15MG/ 30MCG 0.15MG/ 30MCG 35MCG/ 0.25MG 20MCG/ 0.1MG 3MG/ 0.03MG NUVARING ocella portia-28 previfem quasense reclipsen solia sprintec 28 sronyx syeda trinessa tri-previfem tri-sprintec trivora-28 velivet zovia 1/35e zovia 1/50e EVISTA tamoxifen citrate estradiol estropipate Estrogens PREMARIN PREMPHASE Parathyroid Pituitary Progestins Somatotropin Agonists Antithyroid Agents Thyroid Agents PREMPRO calcitonin-salmon FORTICAL desmopressin acetate ENDOMETRIN FIRST-PROGESTERONE VGS 100 COMPOUNDING KIT FIRST-PROGESTERONE VGS 200 COMPOUNDING KIT FIRST-PROGESTERONE VGS 25 COMPOUNDING KIT FIRST-PROGESTERONE VGS 400 COMPOUNDING KIT FIRST-PROGESTERONE VGS 50 COMPOUNDING KIT medroxyprogesterone acetate medroxyprogesterone acetate megestrol acetate megestrol acetate norethindrone acetate TEV-TROPIN methimazole propylthiouracil SSKI ARMOUR THYROID 35MCG/ 1MG 50MCG/ 1MG 60MG 20MG, 10MG 2MG, 1MG, 0.5MG, 37.5MCG/24HR, 0.1MG/24HR, 0.075MG/24HR, 0.06MG/24HR, 0.05MG/24HR, 0.025MG/24HR 3MG, 1.5MG, 0.75MG 1.25MG, 0.9MG, 0.625MG, 0.45MG, 0.3MG, 25MG, 0.625MG/GM 0.625MG/ 5MG 0.625MG/ 5MG, 0.625MG/ 2.5MG, 0.45MG/ 1.5MG, 0.3MG/ 1.5MG 200UNIT/ACT 200UNIT/ACT 0.2MG, 0.1MG, 0.01% 100MG Form TABS RING TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS TABS Coverage Detail QL (91.00 EA per 91 days) TABS, PTWK TABS TABS, SOLR, CREA TABS TABS SOLN SOLN TABS, SOLN INST 100MG SUPP 200MG SUPP 25MG SUPP 400MG SUPP 50MG 150MG/ML 5MG, 2.5MG, 10MG 40MG/ML 40MG, 20MG 5MG 5MG 5MG, 10MG 50MG 1GM/ML 90MG, 60MG, 30MG, 300MG, 240MG, 180MG, 15MG, 120MG SUPP VIAL, SYRINGE TABS SUSP TABS TABS SOLR TABS TABS SOLN QL (1.00 ML per 93 days) QL (600.00 ML per 31 days) PA QL (558.00 EA per 31 days) TABS UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 21 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name Strengths levothroid 88MCG, 75MCG, 50MCG, 300MCG, 25MCG, 200MCG, 175MCG, 150MCG, 137MCG, 125MCG, 112MCG, 100MCG TABS NATURE-THROID NATURE-THROID NT-2.5 np thyroid 30 np thyroid 60 np thyroid 90 88MCG, 75MCG, 50MCG, 300MCG, 25MCG, 200MCG, 175MCG, 150MCG, 137MCG, 125MCG, 112MCG, 500MCG, 100MCG 5MCG, 50MCG, 25MCG 97.5MG, 81.25MG, 65MG, 48.75MG, 32.5MG, 260MG, 195MG, 16.25MG, 146.25MG, 130MG, 113.75MG 162.5MG 30MG 60MG 90MG SYNTHROID THYROLAR-1 THYROLAR-1/2 THYROLAR-1/4 THYROLAR-2 THYROLAR-3 88MCG, 75MCG, 50MCG, 300MCG, 25MCG, 200MCG, 175MCG, 150MCG, 137MCG, 125MCG, 112MCG, 100MCG 60MG 30MG 15MG 120MG 180MG levothyroxine sodium liothyronine sodium Alcohol Deterrents Antidotes Antigout Agents Biologic Response Modifiers TABS TABS TABS TABS TABS TABS lidocaine hcl 2%, 1.5%, 1%, 0.5% SOLN AVODART finasteride disulfiram acetylcysteine 0.5MG 5MG 500MG, 250MG 20%, 10% 5MG, 10MG, 15MG, 25MG, 350MG, 200MG, 100MG, 10MG/ML 300MG, 100MG 500MG 0.6MG 20MG/ML 0.3MG 44MCG/0.5ML, 22MCG/0.5ML CAPS TABS TABS SOLN REBIF REBIF TITRATION PACK THALOMID Bone Resorption Inhibitors TABS TABS TABS TABS TABS WESTHROID leucovorin calcium allopurinol allopurinol sodium COLCRYS COPAXONE EXTAVIA alendronate sodium 50MG, 200MG, 150MG, 100MG 70MG, 5MG, 40MG, 35MG, 10MG Coverage Detail TABS, SOLR TABS 88MCG, 75MCG, 50MCG, 300MCG, 25MCG, 200MCG, 175MCG, 150MCG, 137MCG, 125MCG, 112MCG, 100MCG TABS 150MCG TABS 97.5MG, 81.25MG, 65MG, 48.75MG, 325MG, 32.5MG, 260MG, 195MG, 16.25MG, 146.25MG, 130MG, 113.75MG TABS unithroid unithroid direct LOCAL ANESTHETICS Local Anesthetics MISCELLANEOUS THERAPEUTIC AGENTS 5-alpha-Reductase Inhibitors Form AL (max: 13y) TABS, SOLR, SOLN TABS SOLR TABS KIT SOLR PA PA SOLN SOLN PA PA CAPS PA TABS UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 22 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Cariostatic Agents Product Name PROLIA cavarest dentagel FLUOR-A-DAY fluoridex daily defense karigel karigel-n neutragard advanced phos-flur sf Complement Inhibitors Disease-modifying Antirheumatic Agents Immunosuppressive Agents sodium fluoride FIRAZYR HUMIRA HUMIRA PEN HUMIRA PEN-CROHNS DISEASE STARTER leflunomide SIMPONI azathioprine azathioprine sodium CELLCEPT CELLCEPT INTRAVENOUS cyclosporine OXYTOCICS Oxytocics RESPIRATORY TRACT AGENTS Leukotriene Modifiers Mast-cell Stabilizers Mucolytic Agents Respiratory Tract Agents, Miscellaneous Form SOLN GEL GEL Coverage Detail PA CHEW GEL GEL GEL GEL GEL GEL SOLN, CHEW SOLN KIT KIT CALAFOL RX levocarnitine levocarnitine SUPARTZ methylergonovine maleate 0.2MG, 0.2MG/ML TABS, SOLN SINGULAIR zafirlukast cromolyn sodium broncho saline PULMOZYME sodium chloride sodium chloride KALYDECO XOLAIR 10MG, 4MG, 5MG 20MG, 10MG 20MG/2ML 0.9% 1MG/ML 0.9% 0.9% 150MG 150MG TABS, PACK, CHEW TABS NEBU AERS SOLN NEBU NEBU TABS SOLR PA PA SUSP SUSP PA PA SOLN, LOTN, GEL , CREA PADS SOLN, GEL GEL OINT, CREA CREA GEL OINT SUSP GEL CREA CREA, SOLN OTC-Covered w/Rx SERUMS, TOXOIDS AND VACCINES Vaccines CERVARIX GARDASIL SKIN AND MUCOUS MEMBRANE PREPARATIONS clindamycin phosphate Antibacterials ery erythromycin erythromycin/benzoyl peroxide gentamicin sulfate metronidazole metronidazole vaginal mupirocin sulfacetamide sodium vandazole terbinafine hcl Allylamines clotrimazole Azoles 1%, 2% 2% 2% 5%/ 3% 0.1% 0.75% 0.75% 2% 10% 0.75% 1% 1% KIT TABS SOLN TABS SOLR SUSR SOLR SOLN, CAPS PA PA PA 40MG/0.8ML 20MG, 10MG 50MG/0.5ML 50MG 100MG 200MG/ML 500MG 50MG/ML, 25MG, 100MG 100MG/ML, 50MG, 25MG, 100MG 100MG/ML, 25MG, 100MG 5MG, 1MG, 0.5MG 500MG, 250MG 5MG/ML 50MG/ML, 100MG/ML 5MG, 1MG, 0.5MG 600MG/ 400UNIT/ 1.6MG/ 425MCG/ 5MG/ 25MG 1GM/10ML 330MG, 200MG/ML 25MG/2.5ML cyclosporine modified gengraf hecoria mycophenolate mofetil PROGRAF SANDIMMUNE tacrolimus Other Miscellaneous Therapeutic Agents Strengths 60MG/ML 1.1% 1.1% 1MG/ 236.79MG, 0.25MG/ 236.79MG, 0.5MG/ 236.79MG 1.1% 1.1% 1.1% 1.1% 1.1% 1.1% 0.5MG/ML, 2.2MG, 1MG, 0.5MG, 0.25MG 30MG/3ML 40MG/0.8ML, 20MG/0.4ML 40MG/0.8ML PA PA SOLN, CAPS SOLN, CAPS CAPS TABS, CAPS SOLN SOLN CAPS TABS SOLN TABS, SOLN SOLN QL (900.00 ML per 31 days) PA PA; ST OTC-Covered w/Rx PA OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 23 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Hydroxypyridones Polyenes Antivirals Local Anti-infectives, Miscellaneous Scabicides and Pediculicides Anti-inflammatory Agents Product Name clotrimazole clotrimazole 3 day clotrimazole anti-fungal econazole nitrate GYNE-LOTRIMIN GYNE-LOTRIMIN 3 ketoconazole miconazole miconazole 3 miconazole 3 combo pack miconazole 7 miconazole nitrate MONISTAT 3 MONISTAT 3 COMBINATION PACK MONISTAT 7 MONISTAT 7 COMBINATION PACK terconazole ciclopirox ciclopirox nail lacquer ciclopirox olamine nystatin NYSTATIN VAGINAL DENAVIR acne medication 10 benzoyl peroxide benzoyl peroxide lavoclen-4 creamy wash lavoclen-8 creamy wash Strengths 10MG, 1% 2% 1% 1% 1% 2% 2% 2% 200MG 100MG, 2% 100MG, 2% 4% Form TROC, LOZG, SOLN, CREA CREA CREA CREA CREA CREA SHAM, CREA CREA SUPP KIT SUPP, CREA SUPP, CREA CREA 100MG, 2% KIT SUPP, CREA OTC-Covered w/Rx OTC-Covered w/Rx KIT SUPP, CREA SUSP, GEL SOLN CREA POWD, OINT, CREA TABS CREA GEL GEL LOTN, GEL LIQD LIQD OTC-Covered w/Rx 80MG, 0.8%, 0.4% 0.77% 8% 0.77% 100000UNIT/GM 100000UNIT 1% 10% 5%, 10% 5%, 10% 4% 8% operand chlorhexidine gluconate selenium sulfide silver sulfadiazine ssd acticin OVIDE permethrin 4% 2.5% 1% 1% 5% 0.5% 5% LIQD LOTN CREA CREA CREA LOTN CREA permethrin alclometasone dipropionate amcinonide augmented betamethasone dipropionate betamethasone dipropionate betamethasone valerate clobetasol propionate clobetasol propionate e 1% 0.05% 0.1% LOTN, CREA OINT, CREA LOTN, CREA 0.05% 0.1% 0.1% 0.1% 0.05% CREA OINT, LOTN, CREA OINT, LOTN, CREA OINT, GEL , CREA CREA clobetasol propionate emollient 0.05% 400UNIT/GM/ 1%/ 0.5%/ 5000UNIT/GM 0.05% 0.05% 0.01%, 0.025% 0.01% 0.01% 0.05% 0.05% 0.05% 0.005%, 0.05% 0.05% 100MG/60ML 1% 2.5%, 1% CREA OINT OINT, LOTN, CREA OINT, CREA SOLN, OINT, CREA OIL OIL SOLN, OINT, GEL , CREA CREA CREA OINT, CREA OINT, CREA ENEM OINT, LOTN, CREA OINT, LOTN, CREA 1% CREA CORTISPORIN desonide diflorasone diacetate fluocinolone acetonide fluocinolone acetonide body fluocinolone acetonide scalp fluocinonide fluocinonide emollient base fluocinonide-e fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone hydrocortisone hydrocortisone maximum strength Coverage Detail OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx QL (480.00 ML per 31 days);OTCCovered w/Rx QL (400.00 GM per 31 days) QL (400.00 GM per 31 days) QL (60.00 GM per 31 days) QL (118.00 ML per 31 days) QL (60.00 GM per 31 days) QL (60.00 ML per 31 days);OTCCovered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 24 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Strengths Form Coverage Detail 1% 0.2% 1% 0.1% 2.5% 2.5% 2.5% 0.1%, 0.025% 0.5%, 0.1%, 0.025% 0.1% 5% 4%, 2% 2% 2.5%/ 2.5% 200MG, 100MG 20% CREA OINT, CREA CREA OINT, CREA CREA CREA CREA OINT CREA PSTE OINT SOLN, GEL GEL KIT , CREA TABS SOLN OTC-Covered w/Rx Astringents Product Name hydrocortisone maximum strength plus 12 moisturizers hydrocortisone valerate hydroskin mometasone furoate proctocream hc proctosol hc proctozone-hc triamcinolone acetonide triamcinolone acetonide triamcinolone in orabase lidocaine lidocaine hcl lidocaine hcl jelly lidocaine/prilocaine phenazopyridine hcl hypercare Cell Stimulants and Proliferants avita 0.025% GEL , CREA tretinoin 0.025%, 0.01%, 0.1%, 0.05% GEL , CREA amlactin 12% LOTN ammonium lactate ammonium lactate CLEAR AWAY ONE STEP WART REMOVER CLEAR AWAY PLANTAR SYSTEM CLEAR AWAY WART REMOVER SYSTEM COMPOUND W COMPOUND W MAXIMUM STRENGTH compound w one step plantar pads duofilm FREEZONE remeven salactic film sal-plant scholls corn removers urea WART OFF 12% 12% LOTN, CREA LOTN, CREA AL (max: 20y); QL (45.00 GM per 31 days) AL (max: 20y); QL (45.00 GM per 31 days) QL (400.00 GM per 31 days);OTCCovered w/Rx QL (400.00 GM per 31 days);OTCCovered w/Rx QL (400.00 GM per 31 days) 40% PADS OTC-Covered w/Rx 40% PADS OTC-Covered w/Rx 40% 17% PADS LIQD OTC-Covered w/Rx OTC-Covered w/Rx 17% GEL OTC-Covered w/Rx 40% 17% 17.6% 50% 17% 17% 40% 40% 17% PADS SOLN LIQD CREA SOLN GEL PADS CREA SOLN OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx amnesteem calcipotriene capsaicin 40MG, 20MG, 10MG 0.005% 0.025% CAPS SOLN, OINT CREA claravis CONDYLOX DOVONEX DRITHO-CREME HP 40MG, 30MG, 20MG, 10MG 0.5% 0.005% 1% CAPS GEL CREA CREA ELIDEL fluorouracil podofilox SANTYL 1% 5%, 2% 0.5% 250UNIT/GM CREA SOLN, CREA SOLN OINT sotret 30MG, 20MG, 10MG CAPS Antipruritics and Local Anesthetics Basic Lotions and Liniments Keratolytic Agents Skin and Mucous Membrane Agents, Misc OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx AL (min: 12y, max: 20y); QL (62.00 EA per 31 days); ST; Must fail preferred topical antibiotic; Max duration of therapy 20 weeks OTC-Covered w/Rx AL (min: 12y, max: 20y); QL (62.00 EA per 31 days); ST; Must fail preferred topical antibiotic; Max duration of therapy 20 weeks PA QL (30.00 GM per 31 days); ST; Must fail preferred topical corticosteroid PA PA AL (min: 12y, max: 20y); QL (62.00 EA per 31 days); ST; Must fail preferred topical antibiotic; Max duration of therapy 20 weeks UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 25 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class SMOOTH MUSCLE RELAXANTS Genitourinary Smooth Muscle Relaxants Respiratory Smooth Muscle Relaxants Product Name Strengths Form TAZORAC VOLTAREN 0.1%, 0.05% 1% GEL , CREA GEL oxybutynin chloride oxybutynin chloride oxybutynin chloride er trospium chloride aminophylline theophylline cr 5MG/5ML 5MG 5MG, 15MG, 10MG 20MG 25MG/ML 200MG, 100MG 600MG, 400MG, 450MG, 300MG, 200MG, 100MG SYRP TABS TB24 TABS SOLN TB12 7.5MG/5ML 5MG, 2.5MG, 10MG 500MCG/DOSE/ 50MCG/DOSE, 250MCG/DOSE/ 50MCG/DOSE, 100MCG/DOSE/ 50MCG/DOSE LIQD TABS theophylline er SYMPATHOMIMETIC ADRENERGIC AGENTS alpha-Adrenergic Agonists LUSONAL midodrine hcl Selective beta-2-Adrenergic Agonists ADVAIR DISKUS ADVAIR HFA albuterol sulfate albuterol sulfate albuterol sulfate albuterol sulfate albuterol sulfate COMBIVENT DULERA FORADIL AEROLIZER ipratropium bromide/albuterol sulfate metaproterenol sulfate SEREVENT DISKUS terbutaline sulfate VENTOLIN HFA alpha- and beta-Adrenergic Agonists 45MCG/ACT/ 21MCG/ACT, 230MCG/ACT/ 21MCG/ACT, 115MCG/ACT/ 21MCG/ACT 0.083% 0.5% 1.25MG/3ML, 0.63MG/3ML 2MG/5ML 4MG, 2MG 103MCG/ACT/ 18MCG/ACT 5MCG/ACT/ 200MCG/ACT, 5MCG/ACT/ 100MCG/ACT 12MCG Coverage Detail AL (max: 20y); QL (30.00 GM per 31 days) QL (300.00 GM per 31 days) QL (600.00 ML per 31 days) TB24, TB12 AEPB QL (60.00 EA per 30 days) AERO NEBU NEBU NEBU SYRP TABS AERO QL (12.00 GM per 30 days) QL (720.00 ML per 31 days) QL (60.00 EA per 31 days) QL (300.00 ML per 31 days) QL (2400.00 ML per 31 days) AERO CAPS QL (13.00 GM per 30 days) QL (60.00 EA per 30 days) SOLN SYRP AEPB TABS, SOLN AERS QL (720.00 ML per 31 days) DEVI DEVI DEVI SYRP TABS QL (2.00 EA per 31 days) QL (2.00 EA per 31 days) QL (2.00 EA per 31 days) OTC-Covered w/Rx OTC-Covered w/Rx epinephrine EPIPEN 2-PAK EPIPEN-JR 2-PAK nasal decongestant pseudoephedrine hcl 2.5MG/3ML/ 0.5MG/3ML 10MG/5ML 50MCG/DOSE 5MG, 2.5MG, 1MG/ML 108MCG/ACT 0.3MG/0.3ML, 0.15MG/0.15ML 0.3MG/0.3ML 0.15MG/0.3ML 30MG/5ML 60MG, 30MG SYMBICORT 80MCG/ACT/ 4.5MCG/ACT, 160MCG/ACT/ 4.5MCG/ACT AERO QL (60.00 EA per 30 days) VITAMINS Multivitamin Preparations ELITE-OB 120MG/ 3000UNIT/ 230MG/ 800UNIT/ 2MG/ 12MCG/ 200MG/ 1MG/ 220MCG/ 27MG/ 25MG/ 20MG/ 300MG/ 50MG/ 4MG/ 1.8MG/ 3MG/ 25MG KIT 120MG/ 2100UNIT/ 315UNIT/ 1MG/ 15MCG/ 20UNIT/ 1.25MG/ 50MG/ 15MG/ 10MG/ 10MG/ 3.4MG/ 2MG/ 10MG TABS FOLBECAL 200MG/ 12MCG/ 1MG/ 75MG TABS CAVAN-ALPHA KIT UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 26 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name mynatal advance Strengths 35MG/ML/ 400UNIT/ML/ 2MCG/ML/ 8MG/ML/ 0.4MG/ML/ 0.6MG/ML/ 0.5MG/ML/ 0.5MG/ML/ 5UNIT/ML/ 1500UNIT/ML, 35MG/ML/ 400UNIT/ML/ 2MCG/ML/ 8MG/ML/ 0.4MG/ML/ 0.6MG/ML/ 0.25MG/ML/ 0.5MG/ML/ 5UNIT/ML/ 1500UNIT/ML 35MG/ML/ 400UNIT/ML/ 10MG/ML/ 8MG/ML/ 0.4MG/ML/ 0.6MG/ML/ 0.25MG/ML/ 0.5MG/ML/ 5UNIT/ML/ 1500UNIT/ML 60MG/ 400UNIT/ 4.5MCG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 1MG/ 1.05MG/ 15UNIT/ 2500UNIT, 60MG/ 400UNIT/ 4.5MCG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 0.25MG/ 1.05MG/ 15UNIT/ 2500UNIT, 60MG/ 4.5MCG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 0.5MG/ 1.05MG/ 2500UNIT/ 400UNIT/ 15UNIT 60MG/ 400UNIT/ 4.5MCG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 1MG/ 1.05MG/ 2500UNIT/ 15MG, 60MG/ 400UNIT/ 4.5MCG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 0.5MG/ 1.05MG/ 2500UNIT/ 15MG, 60MG/ 400UNIT/ 4.5MCG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 0.25MG/ 1.05MG/ 2500UNIT/ 15UNIT 37.5MG/ 20MG/ 1MG/ 0.1MG/ 2MG/ 1.5MG/ 5000UNIT/ 400UNIT 60MG/ 400UNIT/ 4.5MCG/ 0.5MG/ 0.3MG/ 13.5MG/ 1.05MG/ 1.2MG/ 0/ 1.05MG/ 2500UNIT/ 15UNIT 120MG/ 200MG/ 400UNIT/ 2MG/ 12MCG/ 50MG/ 1MG/ 90MG/ 30MG/ 20MG/ 20MG/ 3.4MG/ 3MG/ 30UNIT/ 2700UNIT/ 25MG mynatal-z 70MG/ 200MG/ 2.2MCG/ 65MG/ 1MG/ 100MG/ 17MG/ 175MCG/ 2.2MG/ 1.6MG/ 65MCG/ 1.5MG/ 4000UNIT/ 400UNIT/ 10UNIT/ 15MG TABS multi-vit/fluoride multi-vit/iron/fluoride multivitamin/fluoride multi-vitamin/fluoride multivitamins mult-vitamin/fluoride mynate 90 plus polyvitamin Form Coverage Detail SOLN AL (max: 16y) SOLN AL (max: 16y) CHEW AL (max: 16y) CHEW AL (max: 16y) TABS OTC-Covered w/Rx CHEW AL (max: 16y) TABS 120MG/ 250MG/ 2MG/ 12MCG/ 50MG/ 400UNIT/ 90MG/ 1MG/ 20MG/ 0.15MG/ 20MG/ 3.4MG/ 3MG/ 4000UNIT/ 30UNIT/ 25MG TBCR 35MG/ML/ 2MCG/ML/ 8MG/ML/ 0.4MG/ML/ 0.6MG/ML/ 0.5MG/ML/ 1500UNIT/ML/ 400UNIT/ML/ 5UNIT/ML SOLN OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 27 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name poly-vitamin drops polyvitamin/iron poly-vitamin/iron drops Strengths 35MG/ML/ 50MCG/ML/ 2MCG/ML/ 8MG/ML/ 3MG/ML/ 0.4MG/ML/ 0.6MG/ML/ 0.5MG/ML/ 1500UNIT/ML/ 400UNIT/ML/ 5UNIT/ML 35MG/ML/ 400UNIT/ML/ 10MG/ML/ 8MG/ML/ 0.4MG/ML/ 0.6MG/ML/ 0.5MG/ML/ 1500UNIT/ML/ 5UNIT/ML 60MG/ML/ 4.5MCG/ML/ 10MG/ML/ 13.5MG/ML/ 1.05MG/ML/ 1.2MG/ML/ 1.05MG/ML/ 2500UNIT/ML/ 400UNIT/ML/ 11UNIT/ML Form Coverage Detail SOLN OTC-Covered w/Rx SOLN OTC-Covered w/Rx SOLN OTC-Covered w/Rx 120MG/ 3000UNIT/ 200MG/ 400UNIT/ 2MG/ 12MCG/ 275MG/ 1MG/ 29MG/ 25MG/ 20MG/ 400MG/ 25MG/ 4MG/ 1.8MG/ 3MG/ 25MG MISC 120MG/ 200MG/ 400UNIT/ 8MCG/ 1MG/ 29MG/ 20MG/ 150MCG/ 3MG/ 3MG/ 3MG/ 30UNIT/ 15MG TABS PR NATAL 400 EC prenatabs obn prenatal 19 120MG/ 4000UNIT/ 30MCG/ 200MG/ 400UNIT/ 3MG/ 8MCG/ 1MG/ 29MG/ 100MG/ 20MG/ 7MG/ 150MCG/ 3MG/ 3MG/ 3MG/ 30UNIT/ 15MG TABS 100MG/ 1000UNIT/ 200MG/ 7MG/ 12MCG/ 25MG/ 29MG/ 1MG/ 6MG/ 20MG/ 3MG/ 3MG/ 400UNIT/ 30UNIT/ 20MG CHEW prenatal low iron 100MG/ 200MG/ 400UNIT/ 4MCG/ 27MG/ 0.8MG/ 18MG/ 2.6MG/ 1.7MG/ 1.5MG/ 4000UNIT/ 11MG/ 25MG TABS prenatal plus 120MG/ 200MG/ 400UNIT/ 2MG/ 12MCG/ 27MG/ 1MG/ 20MG/ 10MG/ 3MG/ 1.84MG/ 22MG/ 4000UNIT/ 25MG TABS prenatabs rx prenatal plus/iron prenavite multiple vitamin trinatal rx 1 120MG/ 200MG/ 400UNIT/ 2MG/ 12MCG/ 27MG/ 1MG/ 20MG/ 10MG/ 3MG/ 1.84MG/ 22MG/ 4000UNIT/ 25MG TABS 120MG/ 200MG/ 400UNIT/ 8MCG/ 28MG/ 800MCG/ 20MG/ 2.6MG/ 1.7MG/ 1.8MG/ 30UNIT/ 4000UNIT/ 25MG TABS 80MG/ 400UNIT/ 30MCG/ 200MG/ 400UNIT/ 3MG/ 2.5MCG/ 60MG/ 1MG/ 100MG/ 17MG/ 7MG/ 4MG/ 1.6MG/ 1.5MG/ 15UNIT/ 3600UNIT/ 25MG TABS OTC-Covered w/Rx OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 28 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name tri-vitamins Strengths 120MG/ 3000UNIT/ 200MG/ 400UNIT/ 2MG/ 12MCG/ 28MG/ 1MG/ 25MG/ 20MG/ 25MG/ 4MG/ 1.8MG/ 22MG/ 25MG 10MG/ 0.8MG/ 15MCG/ 106.5MG/ 1MG/ 1.3MG/ 30MG/ 5MG/ 6MG/ 200MG/ 10MG 35MG/ML/ 10MG/ML/ 1500UNIT/ML/ 400UNIT/ML 35MG/ML/ 400UNIT/ML/ 0.25MG/ML/ 1500UNIT/ML 35MG/ML/ 0.25MG/ML/ 10MG/ML/ 1500UNIT/ML/ 400UNIT/ML 35MG/ML/ 0.5MG/ML/ 1500UNIT/ML/ 400UNIT/ML 35MG/ML/ 1500UNIT/ML/ 400UNIT/ML ULTIMATECARE COMBO 100MG/ 35MCG/ 45MCG/ 1.3MG/ 12MCG/ 260MG/ 50MG/ 40MG/ 30MG/ 1MG/ 30MG/ 30MG/ 50MCG/ 20MG/ 330MG/ 7MG/ 50MG/ 3.4MG/ 75MCG/ 35MG/ 3MG/ 30UNIT/ 90MCG/ 11MG MISC TRINATE triveen-u TRI-VI-SOL/IRON tri-vit/fluoride TRI-VIT/FLUORIDE/IRON tri-vitamin/fluoride vinate az VINATE AZ EXTRA vinate gt vinate ii vinate m vitamin b complex-c Vitamin A Vitamin B Complex vitamins a/c/d/fluoride vitamin a cyanocobalamin endur-acin folic acid folic acid 120MG/ 3000UNIT/ 30MCG/ 150MG/ 8MG/ 400UNIT/ 2.5MG/ 12MCG/ 27MG/ 1MG/ 75MG/ 20MG/ 30MG/ 3.5MG/ 3MG/ 30UNIT/ 15MG 120MG/ 3000UNIT/ 30MCG/ 8MG/ 400UNIT/ 12MCG/ 29MG/ 1MG/ 75MG/ 20MG/ 50MG/ 3.5MG/ 3MG/ 30UNIT/ 15MG 120MG/ 30MCG/ 200MG/ 6MG/ 400UNIT/ 2MG/ 12MCG/ 50MG/ 1MG/ 90MG/ 30MG/ 20MG/ 20MG/ 3.4MG/ 3MG/ 10UNIT/ 2700UNIT/ 15MG 120MG/ 3000UNIT/ 200MG/ 400UNIT/ 2MG/ 12MCG/ 29MG/ 1MG/ 25MG/ 20MG/ 25MG/ 4MG/ 1.8MG/ 30UNIT/ 25MG 120MG/ 30MCG/ 200MG/ 10MG/ 400UNIT/ 25MCG/ 2MG/ 12MCG/ 27MG/ 1MG/ 25MG/ 5MG/ 20MG/ 150MCG/ 10MG/ 3.4MG/ 25MCG/ 20MCG/ 3MG/ 30UNIT/ 5000UNIT/ 25MG 300MG/ 10MG/ 50MG/ 5MG/ 10.2MG/ 15MG 35MG/ML/ 400UNIT/ML/ 0.25MG/ML/ 1500UNIT/ML 8000UNIT, 10000UNIT 1000MCG/ML 500MG 1MG 800MCG, 400MCG, 1MG Form Coverage Detail TABS CAPS SOLN OTC-Covered w/Rx SOLN AL (max: 16y) SOLN AL (max: 16y) SOLN AL (max: 16y) SOLN OTC-Covered w/Rx TABS TABS TABS TABS TABS CAPS OTC-Covered w/Rx SOLN CAPS SOLN TBCR TABS TABS AL (max: 16y) OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 29 of 30 WellCare Health Plan Kentucky Medicaid Preferred Drug List Class Product Name niacin niacin sr niacin td niacin tr SLO-NIACIN thiamine hcl thiamine hcl vitamin b-1 vitamin b-6 vitamin b-6 tr vitamin b-12 Vitamin D calcitriol vitamin d Strengths 50MG, 500MG, 250MG, 100MG 500MG 500MG 500MG 500MG 100MG/ML 100MG 50MG, 250MG, 100MG 50MG, 500MG, 25MG, 250MG, 100MG 200MG 1000MCG 1MCG/ML, 0.5MCG, 0.25MCG 50000UNIT Form Coverage Detail TABS CPCR TBCR TBCR, CPCR TBCR SOLN TABS TABS OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx TABS TBCR TABS OTC-Covered w/Rx OTC-Covered w/Rx OTC-Covered w/Rx SOLN, CAPS CAPS QL (4.00 EA per 31 days) OTC-Covered w/Rx OTC-Covered w/Rx UPPERCASE=Brand Medications Lowercase italics=Generic Medication Coverage Detail: PA=Prior Authorization ST= Step Edit AL= Age Limit requirement QL= Quantity Limit Page 30 of 30
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