Provider Alerts

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Date:	May 17, 2017
To:	Health Plan of San Joaquin (HPSJ) Physicians and Providers
From:	Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject:	Formulary Update – Effective 7/21/2017
Products:	Medi-Cal, MCAP (Medi-Cal Access Program, previously known as AIM)

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Effective 7/21/2017, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Ethinyl estradiol and norgestimate (Femynor): Quantity limit of 13 cycles per year.
2. Omeprazole (Prilosec) suspension: Step therapy to ranitidine syrup for children <6 years old. Quantity limit: 10mg – 30 packets per month; 2.5mg – 60 packets per month.
3. Dupilumab (Dupixent): PA required. Reserved for patients 18 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 antihistamine at higher than standard doses AND 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.
4. Crisaborole (Eucrisa): Step therapy for patients with atopic dermatitis who have failed treatment, shown intolerance, or has contraindication to a medium to super-high potency topical corticosteroid AND either Pimecrolimus (Elidel) or Tacrolimus (Protopic) within the past 30 days. Limited to 60 grams per 30 days.
5. Differin 0.1% Gel OTC: Restricted to use by patients under 35 years old. For patients over 35, approval will require clinic notes, prior use of topical antibiotics and Benzoyl Peroxide or prescribed by Dermatologist.
6. Lidocaine 3% Cream: No PA required.
7. Lidocaine 4% Cream: No PA required.
8. Lidocaine 5% Anorectal Cream: PA required. Reserved for relief of pain or itching due to anorectal disorder.
9. Rizatriptan 5 mg ODT: No PA required. Limited to 9 tablets per 30 days.
10. Quillichew 30 mg, 40 mg chewable tablets: No PA required.
11. Agrylin (Anagrelide Hydrochloride): No PA required.
12. Chemet (Succimer): No PA required.
13. Ridaura (Auranofin): No PA required.
14. Melatonin 5 mg tablets: No PA required.

Formulary Status Changes:

1. Everolimus (Zortress), sirolimus (Rapamune): PA required. If medication is not being used for post-renal or post-liver transplant, approval is determined by medical necessity criteria. If used for post-renal or post-liver transplant, criteria is as follows:
   1. Post-renal transplant
      1. Sirolimus is reserved for patients with concurrent treatment of cyclosporine or tacrolimus AND mycophenolate or azathioprine
      2. Everolimus is reserved for patients with concurrent treatment of cyclosporine or tacrolimus AND mycophenolate or azathioprine AND treatment failure/contraindication of sirolimus
   2. Post-liver transplant i.
      1. Everolimus is reserved for patients with concurrent treatment of, or documented intolerance/contraindication to, cyclosporine or tacrolimus
2. Filgrastim (Neupogen), tbo-filgrastim (Granix): filgrastim (Neupogen), tbo-filgrastim (Granix) are reserved for documentation of treatment failure of a 1st line agent (filgrastim-sndz (Zarxio), peg-filgrastim (Neulasta)).
3. Acetaminophen-codeine, codeine: Must be greater than or equal to 12 years of age.
4. Tramadol tablets: Must be greater than or equal to 12 years of age.
5. Rhogam: No PA required. Quantity limit of 2 fills per 365 days.

Deletions from the Formulary:

The following products will be removed from the formulary as of July 21, 2017:

Drug	Formulary Alternatives	Grandfather members currently taking
Diltiazem SR 12Hr Capsules	Immediate Release Diltiazem, Diltiazem CD, Diltiazem ER 24hr	Yes
Ortho Tri-Cyclen Lo	Trinessa Lo, Tri-Lo-Marzia, Tri-LoEstarylla, Tri-Lo-Sprintec, Norgestimate (0.18, 0.215, 0.25mg) / Ethinyl Estradiol 25mcg Triphasic	Yes
Phentermine 15mg, 30mg, 37.5mg capsules	Phentermine 37.5 mg tablets	Yes
Differin 0.1% Lotion (Brand)	Adapalene 0.1% Gel, Cream, Lotion (Generic)	No
Adapalene 0.1% Gel (Rx)	Adapalene 0.1% Gel (OTC)	Yes
Benzoyl Peroxide 4% Gel, 4% Creamy Wash, 6% Cleanser	Benzoyl Peroxide 5%, 10% Gel/Lotion/Wash/Liquid	No
Guaifenesin 600 mg ER, 1200 mg ER tablets	Guaifenesin 200 mg IR tablets, 200mg/5mL solution	No

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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 a.m. to 5 p.m. at (209) 942-6340 or 1-888-936-PLAN (7526).

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