Provider Alert – Formulary update effective 12/10/2018
| Date: | September 27, 2018 |
| To: | Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies |
| From: | Health Plan of San Joaquin Pharmacy and Therapeutics Committee |
| Subject: | Provider Alert – Formulary update effective 12/10/2018 |
| Business: | Medi-Cal |
Effective 12/10/2018, the Pharmacy and Therapeutics Committee has approved the following changes:
Additions to the Formulary:
- Abaloparatide (Tymlos) 3120mcg/1.56mL pen-injector: PA required. Reserved for treatment of osteoporosis as evidenced by documented t-score <-2.5 in patients with treatment failure to 1 year of Prolia with calcium supplementation.
- Limited to 1 pen (1.56mL) per 28 days.
- Restricted to Specialty Pharmacy.
- Limited to 24 total months of treatment.
- Antineoplastic Agents: PA required. Approval is determined by medical necessity criteria. May be restricted to Specialty Pharmacy.
Generic Name
Brand Name
Strength
Atezolizumab
Tecentriq
1200 Mg/20
Avelumab
Bavencio
200Mg/10Ml
Bevacizumab
Avastin
25 Mg/Ml
Bexarotene
Targretin
75 Mg
Bleomycin Sulfate
Blenoxane
15 Unit
Bleomycin Sulfate
Blenoxane
30 Unit
Cetuximab
Erbitux
100Mg/50Ml
Cobimetinib Fumarate
Cotellic
20 Mg
Dactinomycin
Cosmegen
0.5 Mg
Daunorubicin Hcl
Cerubidine
5 Mg/Ml
Doxorubicin Hcl
Adriamycin
10 Mg
Doxorubicin Hcl
Adriamycin
50 Mg
Doxorubicin Hcl
Adriamycin
2 Mg/Ml
Doxorubicin Hcl Peg-Liposomal
Doxil/Lipodox
2 Mg/Ml
Durvalumab
Imfinzi
120 Mg/2.4
Durvalumab
Imfinzi
500Mg/10Ml
Epirubicin Hcl
Epirubicin Hcl
50 Mg
Epirubicin Hcl
Epirubicin Hcl
200 Mg
Epirubicin Hcl
Ellence
50 Mg/25Ml
Idarubicin Hcl
Idamycin Pfs
1 Mg/Ml
Irinotecan Hcl
Camptosar
40 Mg/2 Ml
Irinotecan Hcl
Camptosar
300Mg/15Ml
Irinotecan Liposomal
Onivyde
43 Mg/10Ml
Ixabepilone
Ixempra
15 Mg
Ixabepilone
Ixempra
45 Mg
Mitomycin
Mutamycin
5 Mg
Mitomycin
Mutamycin
20 Mg
Mitomycin
Mutamycin
40 Mg
Mitomycin
Mitomycin-Sterile Water 20 Mg/40Ml
Necitumumab
Portrazza
800Mg/50Ml
Panitumumab
Vectibix
100 Mg/5Ml
Pertuzumab
Perjeta
420Mg/14Ml
Streptozocin
Zanosar
1 G
Topotecan Hcl
Hycamtin
0.25 Mg
Topotecan Hcl
Hycamtin
1 Mg
Topotecan Hcl
Hycamtin
4 Mg
Topotecan Hcl
Topotecan Hcl
4 Mg/4 Ml
Trametinib Dimethyl Sulfoxide
Mekinist
0.5 Mg
Trametinib Dimethyl Sulfoxide
Mekinist
2 Mg
Trastuzumab
Herceptin
150 Mg
Trastuzumab
Herceptin
440 Mg
Valrubicin
Valstar
40 Mg/Ml
Vinblastine Sulfate
Vinblastine Sulfate
1 Mg/Ml
Vincristine Sulfate
Vincasar Pfs
1 Mg/Ml
Vincristine Sulfate Liposomal
Marqibo
Fnl 5Mg/31
Vinorelbine Tartrate
Navelbine
10 Mg/Ml
- Insulin Lispro (Admelog) 100 units/mL vial: No restrictions.
- Insulin Lispro (Admelog Solostar) 100 units/mL pen: Limited to 1 box (15mL) per 30 days.
- Ertugliflozin (Steglatro) 5mg, 15mg tablets: Step therapy to an adequate trial of Metformin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
- Ertugliflozin/Metformin (Segluromet) 2.5-500mg, 2.5-1000mg, 7.5-500mg, 7.5-1000mg tablets: No restrictions.
- Irbesartan/Hydrochlorothiazide (Avapro HCT) 150-12.5mg, 300-12.5mg tablets: Step therapy to treatment failure of Losartan 00mg/day in the past 90 days.
- Olmesartan (Benicar): Step therapy to treatment failure of Losartan 100mg/day in the past 90 days.
a. 5mg tablet: Limited to 60 tablets per 30 days.
b. 20mg, 40mg tablet: Limited to 30 tablets per 30 days. - Olmesartan/Hydrochlorothiazide (Benicar HCT) 20-12.5mg, 40-12.5mg, 40-25mg tablets: Step therapy to treatment failure of Losartan 100mg/day in the past 90 days. Limited to 30 tablets per 30 days.
- Tadalafil (Adcirca) 20 mg tablets: PA required. Reserved for treatment failure or intolerance to dose optimized sildenafil for at least 3 months.
- Hepatitis B Vaccine (Recombinant, Adjuvanted) (Heplisav-B): No restrictions.
- Vancomycin (Firvanq) 25mg/mL (300mL bottle only), 50mg/mL solution (150mL and 300mL bottle): PA required. Reserved for Clostridium difficile infections as evidenced by C. difficile toxin assay or C. difficile DNA PCR.
- Vitamin D3 (Cholecalciferol) 2000 unit, 5000 unit tablets: No restrictions.
Formulary Status Changes:
- Teriparatide (Forteo) 600mcg/2.4mL solution: PA required. Reserved for treatment of osteoporosis as evidenced by documented t-score <-2.5 in patients OR with treatment failure to year of Prolia with calcium supplementation AND treatment failure or intolerance to Abaloparatide.
- Limited to 1 pen (2.4mL) per 28 days.
- Restricted to Specialty Pharmacy.
- Limited to 24 total months of treatment.
- Risedronate (Actonel): PA required. Reserved for treatment failure or intolerance to [1] Alendronate (Fosamax), and [2] Ibandronate (Boniva) unless patient has documented high risk factors for hip or non-vertebral fractures. Current quantity limits on all formulary strengths will still apply.
- Insulin Glargine (Basaglar Kwikpen) 100 units/mL pen: Limited to 1 box (15mL) per 30 days.
- Invokana (Canagliflozin) 100mg, 300mg tablets: Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
- Farxiga (Dapagliflozin) 5mg, 10mg tablets: Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
- Invokamet (Canagliflozin/Metformin) IR/XR 50mg-500mg, 50mg-1000mg, 150mg-500mg, 150-1000mg tablets: Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated. Limited to 60 tablets per 30 days.
- Xigduo XR (Dapagliflozin/Metformin): Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated.
- 5mg-500mg, 5mg-1000mg tablets: Limited to 60 tablets per 30 days.
- 10mg-500mg, 10mg-1000mg tablets: Limited to 30 tablets per 30 days.
- Irbesartan (Avapro) 75mg, 150mg, 300mg tablets: Step therapy to treatment failure of Losartan 100mg/day in the past 90 days.
- Clonidine (Catapres-TTS) 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr patches: PA required. Reserved for documented inability to take medications by mouth. Limited to 4 patches per 28 days.
- Orlistat (Xenical, Alli), Phentermine 37.5 mg tablets: PA required. Reserved for individuals who have received exercise and dietary counseling at least twice by a registered dietitian AND one of the following: [1] BMI of ≥ 27 with 2 or more comorbidities OR [2] BMI > 30.
- Hepatitis C Coverage Criteria per DHCS (effective 07/01/2018): Treatment is recommended for all patients with chronic HCV infection, except those with a short life expectancy who cannot be remediated by HCV therapy, liver transplantation, or another directed therapy.
Deletions from the Formulary:
The following products will be removed from the formulary as of December 10, 2018:
|
Drug |
Formulary Alternatives |
Grandfather members |
|
Humalog 100 units/mL |
Admelog 100 units/mL Vials and Solostar |
Yes |
|
Cardizem LA 120mg, |
Cardizem CD capsules: 120mg, 180mg, 240mg, 300mg |
Yes |
|
Matzim LA 180mg, |
Cardizem CD capsules: 120mg, 180mg, 240mg, 300mg |
Yes |
|
Vancomycin 125mg capsules |
Vancomycin (Firvanq) 25 mg/mL (300mL bottle), 50 mg/mL solution (150mL, 300mL bottle) |
No |
Health Plan of San Joaquin is dedicated to providing all members the best health care available in the most effective and efficient manner. We believe that this change in our Pharmacy Drug Benefit will not affect the quality of the care you provide.
You may contact our Customer Service Department with any questions or concerns Monday through Friday 8 a.m. to 5 p.m. at (209) 942-6320 or 1-888-936-PLAN (7526). Thank you for your continued support of Health Plan of San Joaquin.