Provider Alerts

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To:	Health Plan of San Joaquin (HPSJ) Physicians and Providers
From:	Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject:	Formulary Update
Products:	Medi-Cal, AIM

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Effective 4/1/2015, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Zoledronic Acid (Reclast 5mg IV) – PA required. Reserved for patients with documentation of inability to swallow tablets. Limit 1 fill (5mg) per 365 days.
2. Denosumab (Prolia 60mg/ml) – PA required. Reserved for treatment of osteoporosis as evidenced by documented T-score < -2.5 in patients with treatment failure to 1 year of bisphosphonate with calcium supplementation or failure/intolerance to 2 formulary bisphosphonates. Limit 1 per 180 days.
3. Balsalazide (Colazal) – No PA required.
4. Budesonide (Entocort EC) – PA required. Reserved for induction of remission of Crohn’s disease or Ulcerative Colitis for patients intolerant to conventional glucocorticoids (e.g., prednisone, methylprednisolone). Approved up to 90 days of therapy.
5. Ledipasvir/sofosbuvir (Harvoni) – PA required. Reserved for treatment of Hepatitis C in patients who meet all requirements for treatment based on the Department of Health Care Services (DHCS) Policy for Management of Hepatitis C.
6. Apixaban (Eliquis) – PA required. Limit 60 per month. Dose-reduced therapy is required based on age (>80), weight (<60kg), renal function (SCr >1.5 mg/dL) as noted in the prescribing information. Criteria for indications as follows: 
   1. Atrial Fibrillation: Reserved for treatment of atrial fibrillation without history or high risk of GI bleeding AND who have a high risk of stroke defined as CHADS2 score ≥
   2. DVT/PE treatment: Reserved for patients who are intolerant to or fail to achieve therapeutic INRs on warfarin therapy despite an adequate trial that includes dose titration and patient education. 
   3. DVT/PE prevention: Reserved for patients who are status-post hip surgery (35 days) or post-knee surgery (14 days).

Formulary Status Changes:

1. Short-acting opiates (e.g., Hydrocodone/APAP, Oxycodone, Hydromorphone, Tramadol) – Limited to a combined total 120 tablets/capsules per month.
2. Teriparatide (Forteo) – 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. Maximum of 1 dose every 180 days. Treatment for osteoporosis is limited to a total of 24 months. Page 2 of 2 Formulary Update May 5, 2015 3.
3. Calcitonin Nasal Spray (Miacalcin/Fortical) – PA required. Due to questionable efficacy, Calcitonin intranasal spray is reserved for patients for whom there is documentation that ALL other options for treatment of osteoporosis are either contraindicated, not tolerated, or have been ineffective.
4. Mesalamine Suppositories (Canasa) – PA required. Reserved for treatment failure, contraindication, or inability to use mesalamine enema.
5. Mesalamine (Delzicol) – PA Required. Reserved for documentation of treatment failure of Balsalazide, Sulfasalazine, or Mesalamine Enema for at least 3 months. Delzicol may be used for induction of remission and/or maintenance therapy.
6. Mesalamine (Pentasa) – PA required. Reserved for induction of remission and/or maintenance of Ulcerative Colitis with clinical documentation of ileal disease.
7. Rivaroxaban (Xarelto) – PA required. Limited to 1 tablet daily (except 15mg tablet, which may be approved for twice daily for up to 21 days). Documentation of renal function is required for non-standard dosing. Criteria for indications as follows: 
   1. Atrial Fibrillation: Reserved for treatment of atrial fibrillation without history or high risk of GI bleeding AND who have a high risk of stroke defined as CHADS2 score ≥ 2. 
   2. DVT/PE treatment: Reserved for patients who are intolerant to or fail to achieve therapeutic INRs on warfarin therapy despite an adequate trial that includes dose titration and patient education. 
   3. DVT/PE prevention: Reserved for patients who are status-post hip surgery (35 days) or post-knee surgery (14 days).

Deletions from the Formulary:
The following products were removed from the formulary as of April 1, 2015:

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 Provider Services Department with any questions or concerns Monday through Friday 8:00 am to 5:00 pm at (209) 942-6340 or 1-888-936-PLAN.

Thank you for your continued support of Health Plan of San Joaquin