Formulary Update – Effective 02/01/2021

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Date: December 14, 2020
To: Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies
From: Health Plan of San Joaquin
Subject: Formulary Update
Business: Medi-Cal

Effective 02/01/2021, the Pharmacy and Therapeutics Committee has approved the following changes:

Formulary Status Changes

  1. For Hidradenitis Suppurativa – Adalimumab (Humira) 10mg/0.2mL, 20mg/0.2mL, 40mg/0.4mL, and 80mg/0.8mL syringe/pen: PA required. Reserved for patients at least 12 years of age with documented diagnosis of moderate to severe hidradenitis suppurativa for at least one year. Must be prescribed by Dermatologist. Restricted to specialty pharmacy.
  2. For Atopic Dermatitis – Dupilumab (Dupixent) 300 mg/2 ml syringe: PA required. Reserved for patients 6 years of age or older with confirmed diagnosis by a dermatologist, allergist, or immunologist of chronic moderate to severe atopic dermatitis that has failed treatment, shown intolerance, or has contraindication to one or more medium to super-high potency topical corticosteroid AND Tacrolimus (Protopic) AND an adequate trial of one of the following [1] phototherapy/photo-chemotherapy OR [2] oral systemic therapy (e.g. azathioprine, methotrexate, mycophenolate) within the past 365 days. Documentation of allergy testing (e.g. skin, in vitro) is also required. Must be prescribed by Dermatologist. Restricted to specialty pharmacy.
  3. Erenumab (Aimovig) 70mg/mL, 140mg/mL auto-injector; Fremanezumab (Ajovy) 225mg/1.5mL syringe; Galcanezumab (Emgality) 120mg/mL auto injector/syringe: PA required. Reserved for patients who have failed 6 months of therapy with Botox and are 18 years of age or older. Must be prescribed by a Neurologist.
    1. Aimovig: Limited to 1 injection per month.
    2. Ajovy: Limited to 3 injections per 3 months.
    3. Emgality: Limited to 1 injection per month.
  4. Hydroxyprogesterone caproate (Makena®) 250mg/ml vials, 1250mg/5ml vials: PA required. Singleton pregnancy with history of spontaneous preterm birth (less than 37 weeks). Therapy should be initiated between 16 and 20 weeks, 6 days. Limited to 5ml per 35 days. 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. Thank you for your continued support of Health Plan of San Joaquin.

Posted on December 16th, 2020 and last modified on December 16th, 2020.

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