2021 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) Lista integral de medicamentos preferidos de South Carolina Medicaid (Lista de medicamentos cubiertos) WellCare of South Carolina 00 Please read: This document contains information about the drugs we cover in this plan. Please note: The South Carolina Medicaid Preferred Drug List is updated quarterly. Providers, please visit our website at https://www.wellcare.com/South- Carolina/Providers/Medicaid/Pharmacy to view updates to the preferred drug list. Members, please visit our website at https://www.wellcare.com/South-Carolina/Members/Medicaid-Plans/WellCare-of-South-Carolina/Pharmacy- Services to view updates to the preferred drug list. Importante: Este documento contiene información acerca de los medicamentos que tienen cobertura con este plan. Tenga en cuenta lo siguiente: La lista de medicamentos preferidos de South Carolina Medicaid se actualiza cada trimestre. Proveedores: visite nuestro sitio web en https://www.wellcare.com/South- Carolina/Providers/Medicaid/Pharmacy para ver las actualizaciones de la lista de medicamentos preferidos. Miembros: visite nuestro sitio web en https://www.wellcare.com/South-Carolina/Members/Medicaid-Plans/WellCare-of-South-Carolina/Pharmacy- Services para ver las actualizaciones de la lista de medicamentos preferidos. Last updated (4/1/2021) Última actualización (4/1/2021) CAD_67295M State Approved 01282021 ©WellCare 2021 SC1SMDCVR68980M_2021 Drug Name Preference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti- Obesity/Anorexiants* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended P release 24 hour 1 mg, 2 mg, 3 mg, 4 mg *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** atomoxetine hcl oral capsule 10 mg, 100 mg, P QL (31 EA per 31 days) 40 mg, 60 mg, 80 mg atomoxetine hcl oral capsule 18 mg P QL (62 EA per 31 days) atomoxetine hcl oral capsule 25 mg P QL (93 EA per 31 days) *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule QL (62 EA per 31 days); AL extended release 24 hour 10 mg, 15 mg, 20 P (Min 6 Years and Max 20 mg, 25 mg, 30 mg, 5 mg Years) amphetamine-dextroamphetamine oral tablet P 10 mg, 12.5 mg, 15 mg, 5 mg, 7.5 mg amphetamine-dextroamphetamine oral tablet P QL (93 EA per 31 days) 20 mg amphetamine-dextroamphetamine oral tablet P QL (62 EA per 31 days) 30 mg *Amphetamines*** dextroamphetamine sulfate er oral capsule QL (31 EA per 31 days); AL extended release 24 hour 10 mg, 15 mg, 5 P (Min 6 Years and Max 20 mg Years) dextroamphetamine sulfate oral tablet 10 mg, P 5 mg *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule QL (31 EA per 31 days); AL extended release 24 hour 10 mg, 15 mg, 20 P (Min 6 Years and Max 20 mg, 30 mg, 40 mg, 5 mg Years) dexmethylphenidate hcl oral tablet 10 mg, QL (62 EA per 31 days); AL P 2.5 mg, 5 mg (Min 6 Years) QL (93 EA per 31 days); AL methylphenidate hcl er oral tablet extended P (Min 6 Years and Max 20 release 10 mg, 20 mg Years) QL (62 EA per 31 days); AL methylphenidate hcl er oral tablet extended P (Min 6 Years and Max 20 release 18 mg, 27 mg, 36 mg Years) P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 1 Drug Name Preference Details Coverage Details QL (62 EA per 31 days); AL methylphenidate hcl er oral tablet extended P (Min 6 Years and Max 20 release 24 hour 18 mg, 27 mg, 36 mg Years) QL (31 EA per 31 days); AL methylphenidate hcl er oral tablet extended P (Min 6 Years and Max 20 release 24 hour 54 mg Years) QL (31 EA per 31 days); AL methylphenidate hcl er oral tablet extended P (Min 6 Years and Max 20 release 54 mg Years) methylphenidate hcl oral tablet 10 mg, 5 mg P AL (Min 6 Years) QL (93 EA per 31 days); AL methylphenidate hcl oral tablet 20 mg P (Min 6 Years) methylphenidate hcl oral tablet chewable 10 P AL (Min 6 Years) mg, 2.5 mg, 5 mg Modafinil Oral Tablet 100 MG, 200 MG Non-Formulary *Alternative Medicines* *Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 mg P melatonin oral tablet 12 mg P *Aminoglycosides* *Aminoglycosides*** tobramycin inhalation nebulization solution P PA 300 mg/4ml *Analgesics - Anti-Inflammatory* *Antirheumatic - Janus Kinase (Jak) Inhibitors*** XELJANZ ORAL TABLET 10 MG, 5 MG P PA; QL (62 EA per 31 days) XELJANZ XR ORAL TABLET EXTENDED P PA; QL (31 EA per 31 days) RELEASE 24 HOUR 11 MG, 22 MG *Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE P PA KIT 80 MG/0.8ML HUMIRA PEN SUBCUTANEOUS PEN- P PA INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 P PA MG/0.8ML P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 2 Drug Name Preference Details Coverage Details HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, P PA 20 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML, 40 MG/0.8ML *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100 mg, 50 mg P QL (62 EA per 31 days) celecoxib oral capsule 200 mg, 400 mg P QL (31 EA per 31 days) *Interleukin-6 Receptor Inhibitors*** KEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/1.14ML, 200 P PA MG/1.14ML KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/1.14ML, 200 P PA MG/1.14ML *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen oral suspension 100 P mg/5ml diclofenac potassium oral tablet 50 mg P diclofenac sodium er oral tablet extended P release 24 hour 100 mg diclofenac sodium oral tablet delayed release P 25 mg, 50 mg, 75 mg etodolac oral capsule 200 mg, 300 mg P etodolac oral tablet 400 mg, 500 mg P flurbiprofen oral tablet 100 mg, 50 mg P ibuprofen childrens oral suspension 100 P mg/5ml ibuprofen oral suspension 100 mg/5ml P ibuprofen oral tablet 200 mg, 400 mg, 600 P mg, 800 mg indomethacin oral capsule 25 mg, 50 mg P infants ibuprofen oral suspension 50 P mg/1.25ml ketoprofen oral capsule 50 mg, 75 mg P Max quantity of 20, Max day ketorolac tromethamine oral tablet 10 mg P supply of 5 per a calendar month; QL (20 EA per 31 days) meloxicam oral tablet 15 mg, 7.5 mg P P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 3 Drug Name Preference Details Coverage Details nabumetone oral tablet 500 mg, 750 mg P naproxen dr oral tablet delayed release 375 P mg, 500 mg naproxen oral tablet 250 mg, 375 mg, 500 P mg naproxen sodium oral tablet 220 mg P oxaprozin oral tablet 600 mg P piroxicam oral capsule 10 mg, 20 mg P sulindac oral tablet 150 mg, 200 mg P *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10 mg, 20 mg P *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL MINI SUBCUTANEOUS P PA SOLUTION CARTRIDGE 50 MG/ML ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 P PA MG/ML ENBREL SUBCUTANEOUS SOLUTION P PA RECONSTITUTED 25 MG ENBREL SURECLICK SUBCUTANEOUS P PA SOLUTION AUTO-INJECTOR 50 MG/ML *Analgesics - Nonnarcotic* *Analgesics Other*** acetaminophen extra strength oral liquid 500 P mg/15ml acetaminophen oral solution 160 mg/5ml P acetaminophen oral tablet 325 mg P QL (279 EA per 31 days) acetaminophen oral tablet 500 mg P QL (186 EA per 31 days) acetaminophen rectal suppository 650 mg P apap oral tablet 325 mg P QL (279 EA per 31 days) childrens non-aspirin oral suspension 160 P mg/5ml infants silapap oral solution 100 mg/ml P mapap oral liquid 160 mg/5ml P pain & fever childrens oral suspension 160 P mg/5ml P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 4 Drug Name Preference Details Coverage Details *Analgesics-Sedatives*** butalbital-acetaminophen oral tablet 50-325 P QL (186 EA per 31 days) mg butalbital-apap-caffeine oral capsule 50-325- P QL (186 EA per 31 days) 40 mg butalbital-apap-caffeine oral tablet 50-325-40 P QL (186 EA per 31 days) mg butalbital-asa-caffeine oral capsule 50-325- P 40 mg marten-tab oral tablet 50-325 mg P QL (186 EA per 31 days) *Salicylates*** aspirin ec oral tablet delayed release 325 P mg, 81 mg aspirin low dose oral tablet chewable 81 mg P aspirin oral tablet 325 mg P aspirin oral tablet delayed release 81 mg P aspirin rectal suppository 600 mg P diflunisal oral tablet 500 mg P eq aspirin low dose oral tablet delayed P release 81 mg salsalate oral tablet 500 mg, 750 mg P *Analgesics - Opioid* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet 300-15 P mg acetaminophen-codeine #3 oral tablet 300-30 P mg acetaminophen-codeine #4 oral tablet 300-60 P mg acetaminophen-codeine oral solution 120-12 P mg/5ml ASCOMP-CODEINE ORAL CAPSULE 50- P 325-40-30 MG butalbital-apap-caff-cod oral capsule 50-325- P 40-30 mg butalbital-asa-caff-codeine oral capsule 50- P 325-40-30 mg P=Preferred, Asterisk(*)=N/A, PA=Prior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, OTC Products Require Rx, UPPERCASE= Brand name drugs/ lowercase italics= Generic drugs 5 Drug Name Preference Details Coverage Details *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution P 7.5-325 mg/15ml hydrocodone-acetaminophen oral tablet 10- P 325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 7.5-200 P mg *Opioid