Formulary Update – Effective 07/19/2021

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Date: May 13, 2021
To: Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies
From: Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject: Formulary Update – Effective 07/19/2021
Business: Medi-Cal

Effective 07/19/2021, the Pharmacy and Therapeutics Committee has approved the following changes.

Additions to the Formulary

  1. Teprotumumab (Tepezza) 500mg vial: Reserved for moderate-to-severe thyroid associated orbitopathy with all the following:
    • Clinical Activity Score for Graves Orbitopathy ≥4
    • Treatment/Failure of a 4-week trial of a systemic corticosteroid (at up to maximally indicated doses), unless clinically significant adverse effects are experienced, or all are contraindicated
    • Patient must not have had a history of surgical intervention for thyroideye disease
    • Patient must not have had optic nerve involvement within the last six months
    • Patient must not have planned surgical ophthalmological intervention during Tepezza use
    • Limited to 8 fills/doses total
    • Prescribed by an endocrinologist/ophthalmologist
  2. For Psoriatic Arthritis: Gulselkumab (Tremfya) 100mg/ml injector, syringe: Reserved for treatment failure/documented intolerance to Adalimumab, Etanercept, or Infliximab. Must be prescribed by a rheumatologist or dermatologist. Restricted to specialty pharmacy.
  3. Valacyclovir 500mg tablet, 1gram tablet: No restrictions.
  4. Famciclovir 125mg, 250mg, and 500mg tablet: No restrictions.

Formulary Status Changes

  1. Albendazole (Albenza) 200mg tablet: Limited to 4 tablets per 365 days.
  2. Medical Benefit – J3489 – Zoledronic Acid, 1mg: Limited to 5 units per 365 days.
  3. Medical Benefit – J9260-Methotrexate Sodium, 50mg: Limited to 4 units per 28 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 or 1-888-936-PLAN (7526), or TDD/TYY 711. Thank you for your continued support of Health Plan of San Joaquin

Posted on May 13th, 2021 and last modified on May 18th, 2021.

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