Formulary Update effective 8/19/2019

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Date: June 12, 2019
To: Health Plan of San Joaquin (HPSJ) Practitioners, Providers and Facilities
From: Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject: Formulary Update effective 8/19/2019
Business: Medi-Cal

Effective 8/19/2019, the Pharmacy and Therapeutics Committee has approved the following changes:
 
Additions to the Formulary:

  1. Semaglutide (Ozempic) Pen Injector:  PA required.  Reserved for an inadequate response to 3 months of compliant use of dose-optimized Metformin with Jardiance AND metformin with Invokana (unless intolerant or contraindicated) with A1c <10%.  A trial of Metformin ER is required if intolerance is GI-related.  Patients must also have received and dietary counseling at least twice by a registered dietician.
  2. Alogliptin (Nesina) Tablet:  PA required.  Reserved for inadequate response to an adequate and concurrent trial of metformin, unless intolerant or contraindicated. A documented trial of Metformin Extended-Release is required if metformin cannot be tolerated due to gastrointestinal side effects. Alogliptin is reserved for patients who have tried and failed both Januvia and Tradjenta.  Limited to 30 tablets per 30 days.
  3. Alogliptin/Metformin (Kazano) Tablet:  PA required.   Reserved for patients who have tried and failed both Januvia and Tradjenta. Limited to 60 tablets per 30 days.
  4. Adalimumab 40mg/ 0.4ml (Humira CF):  Reserved for treatment failure to 12 weeks of doseoptimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Acitretin, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Restricted to specialty pharmacy.  Must be prescribed by specialist.
  5. Guselkumab(Tremfya) One Press Injector, Tildrakizumab (Ilumya) Syringe:  PA required.  Reserved for treatment failure/documented intolerance to Adalimumab, Etanercept, or Infliximab. Restricted to specialty pharmacy.  Must be prescribed by dermatologist.
  6. Vedolizumab (Entyvio) Vial for Crohn’s Disease (CD) or Ulcerative Colitis (UC):  PA required.  Reserved for patients with contraindication to ALL other agents.   Restricted to specialty pharmacy.  Must be prescribed by gastroenterologist.
  7. Baricitinib (Olumiant): PA required.  Reserved for treatment of rheumatoid arthritis (RA) with treatment failure to Adalimumab, Etanercept, Infliximab, Sarilumab, or Abatacept.  Restricted to specialty pharmacy.  Must be prescribed by a rheumatologist.  Limited to 30 tablets per 30 days.
  8. Sodium Bicarbonate 650mg tablets: No restrictions.
  9. Daily-Vite Tablets: No restrictions.
  10. Insulin aspart (Fiasp):
      1. Vials: No restrictions.
      2. Pens: Limited to 15 mL per 60 days.
  11. Toujeo Max Solostar: PA required. Toujeo is reserved for patients requiring more than 80 units of insulin glargine per injection.

Formulary Status Changes:

    1. Methadone Tablets/Solution: Limited to a maximum of 40mg per day.  Note all opioids are still limited to a combined dose limit of <90 MME/day.
      • Methadone 10mg tablets Limit 120 tablets per 30 days
        Methadone 5mg tablets Limit 240 tablets per 30 days
        Methadone 5mg/5ml oral solution Limit 1200ml per 30 days
        Methadone 10mg/5ml oral solution Limit 600ml per 30 days
        Methadone 10mg/10ml oral concentrate Limit 120ml per 30 days
    2. Mesalamine (Pentasa) ER Capsule, (Asacol HD, Lialda) Tablet:  PA required.   Reserved for treatment failure or intolerance to Delzicol or Apriso for 3 months. Limited to 120 tablets per 30 days.
    3. Mesalamine (Delzicol) 400mg Capsule:  PA required.  Treatment failure or intolerance to Balsalazide, Sulfasalazine, or Mesalamine enema for 3 months for induction or maintenance.
    4. Budesonide (Entecort EC) ER Capsule:  PA required.  Reserved for induction of remission in those intolerant to conventional glucocorticoids.  Limited to 90 capsules per 30 days, 4 fills per 365 days.
    5. Certolizumab (Cimzia) Syringe for CD, Golimumab (Simponi) Injection for UC:  PA required.  Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids.   Restricted to specialty pharmacy.  Must be initiated by a gastroenterologist.
    6. Natalizumab (Tysabri) for CD:  PA required.  Reserved for patients with contraindication to ALL other agents.   Restricted to specialty pharmacy.  Must be initiated by a gastroenterologist.
    7. Ustekininumab (Stelara) for CD:  PA required.  Reserved for treatment failure to Corticosteroids, Thiopurines, Methotrexate, and TNF inhibitors.  Restricted to specialty pharmacy.  Must be initiated by a gastroenterologist.
    8. Tofacitinib (Xeljanz) Tablets
      1. For UC remission:  PA required. Reserved for treatment failure or intolerance to TNF inhibitors.  Restricted to specialty pharmacy.  Must be initiated by a gastroenterologist.
      2. For RA: PA required.  Reserved for treatment of rheumatoid arthritis with treatment failure or contraindication to Baricitinib.  Restricted to specialty pharmacy.  Must be initiated by a rheumatologist.
      3. For PsA: PA required.  Reserved for treatment failure/documented intolerance to two 1st line agents (Adalimumab, Etanercept, or Infliximab) OR one 1st line agent
        (Adalimumab, Etanercept, or Infliximab) and one 2nd line agent (Certolizumab, Golimumab, Secukinumab).  Restricted to specialty pharmacy.  Must be prescribed by a rheumatologist or dermatologist.
      4. Xeljanz 5mg tablets: Limited to 60 tablets per 30 days.
      5. Xeljanz 11mg XR tablets: Limited to 30 tablets per 30 days.
    9. Abatacept (Orencia) for RA:  PA required. Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy.  If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.  Restricted to specialty pharmacy.  Must be initiated by a rheumatologist.
    10. Lupiprostone (Amitiza) Capsule:  PA required.   Reserved for women 18 year and older who have failed treatment with linaclotide (Linzess) or naloxegol (Movantik). Patient must have also failed regularly scheduled, dose optimized polyethylene glycol (Miralax), AND two of the following: bisacodyl, Senna, psyllium magnesium citrate or hydroxide.
    11. Sodium Oxybate (Xyrem) Solution:  PA required.  Reserved for use in narcolepsy with cataplexy who meet all of the following criteria:
      1. Treated by a sleep specialist or pulmonologist;
      2. Treatment failure to 4 weeks of ALL of the following: Fluoxetine, Venlafaxine, and tricyclic antidepressant;
      3. Limited to 540 ml per 30 days.
    12. Modafinil (Provigil) Tablet:   PA required.   Reserved for treatment of narcolepsy, shift work sleep disorder, or obstructive sleep apnea treated by a sleep specialist or pulmonologist. For apnea, reserved for inadequate response to compliant use of properly-fitting CPAP for at least 90 days.
    13. Pyridostigmine Bromide 60mg/5mL syrup: PA required. Reserved for patients with documented inability to consume pyridostigmine tablets by mouth.
    14. Pyridostigmine Bromide 5mg/mL injection: PA required. Reserved for patients with documented inability to consume pyridostigmine tablets or syrup by mouth.
    15. Pyridostigmine Bromide 60mg/5mL 180mg ER tablet: PA required. Reserved for patients with treatment failure to optimally dosed, compliant use of pyridostigmine IR tablets.
    16. Liraglutide (Victoza): PA required. Reserved for an inadequate response to 3 months of compliant use of dose-optimized Metformin with Jardiance AND metformin with Invokana (unless intolerant or contraindicated) AND Ozempic with A1c <10%. A trial of Metformin ER is required if intolerance is GI-related. Patients must also have received exercise and dietary counseling at least twice by a registered dietician.
    17. Exenatide (Byetta/Bydureon/Bydureon BCise):  PA required. Reserved for an inadequate response to 3 months of compliant use of dose-optimized Metformin with Jardiance AND metformin with Invokana (unless intolerant or contraindicated) AND Ozempic AND Victoza with A1c <10%. A trial of Metformin ER is required if intolerance is GI-related. Patients must also have received exercise and dietary counseling at least twice by a registered dietician.
    18. Saxagliptin (Onglyza) Tablet:  PA required.   Reserved for inadequate response to an adequate and concurrent trial of metformin, unless intolerant or contraindicated. A documented trial of Metformin Extended-Release is required if metformin cannot be tolerated due to gastrointestinal side effects. Onglyza is reserved for patients who have tried and failed Januvia, Tradjenta and Nesina.  Limited to 30 tablets per 30 days.
    19. Saxagliptin/Metformin (Kombiglyze XR) Tablet:   PA required.  Reserved for patients who have tried and failed Januvia, Tradjenta, and Nesina.
      1. 2.5mg-1000mg – Limited to 60 tablets per 30 days.
      2. 5mg-500mg, 5mg-1000mg – Limited to 60 tablets per 30 days.
    20. Atomoxetine (Strattera), Guanfacine ER (Intuniv): Step therapy to stimulant ADHD medications. Limited to persons ≥4 years of age.
    21. Dexmethylphenidate IR tablets, Methylphenidate IR tablets/solution, Dextroamphetamine IR tablets, Dextroamphetamine/Amphetamine IR tablets: Limited to persons ≥4 years of age.
    22. Pimecrolimus (Elidel) Ointment:  Step therapy to 1 fill of a formulary medium/high potency topical corticosteroid AND Tacrolimus ointment in the last 30 days.  Limited to 30 grams per 30 days.
    23. Step 2 listed agents require step therapy to one fill of a step 1 listed agent in the corresponding topical steroid potency class within the last 30 days.  Class 1 potency steroids have a quantity limit of 60g per 90 days, except for clobetasol shampoo with a quantity limit of 118 mL per 90 days.
  1. Step 1

    Step 2

    Class 1 – Super High Potency
    CLOBETASOL PROPIONATE 0.05 % SOLUTION
    CLOBETASOL PROPIONATE 0.05 % OINT. (G)
    CLOBETASOL PROPIONATE 0.05 % CREAM (G)
    CLOBETASOL PROPIONATE 0.05 % GEL (GRAM)
    CLOBETASOL PROPIONATE 0.05 % SHAMPOO
    HALOBETASOL PROPIONATE 0.05 % OINT. (G)
    HALOBETASOL PROPIONATE 0.05 % CREAM (G)
    Class 2 – High Potency
    TRIAMCINOLONE ACETONIDE 0.5 % CREAM TRIAMCINOLONE ACETONIDE 0.5 % OINT. (G) FLUOCINONIDE/EMOLLIENT BASE 0.05 % CREAM (G)
    Class 3 – Upper Mid Potency
    FLUOCINONIDE 0.05 % SOLUTION
    MOMETASONE FUROATE 0.1 % OINT. (G)
    BETAMETHASONE VALERATE 0.1 % OINT. (G)
    FLUOCINONIDE 0.05 % GEL (GRAM)
    FLUOCINONIDE 0.05 % CREAM (G)
    FLUOCINONIDE 0.05 % OINT. (G)
    Class 4 – Medium Potency
    FLUOCINOLONE/SHOWER CAP 0.01 % OIL
    TRIAMCINOLONE ACETONIDE 0.1 % OINT. (G)
    TRIAMCINOLONE ACETONIDE 0.1 % LOTION MOMETASONE FUROATE 0.1 % CREAM (G)
    Class 5 – Lower Mid Potency
    HYDROCORTISONE 1 % LOTION
    HYDROCORTISONE ACETATE 1 % CREAM (G)
    HYDROCORTISONE ACETATE 1 % OINT. (G)
    HYDROCORTISONE 1 % CREAM (G)
    HYDROCORTISONE 2.5 % CREAM (G)
    HYDROCORTISONE 1 % OINT. (G)
    HYDROCORTISONE 2.5 % OINT. (G)
    HYDROCORTISONE 1 % LOTION
    HYDROCORTISONE 2.5 % LOTION
    TRIAMCINOLONE ACETONIDE 0.1 % CREAM
    TRIAMCINOLONE ACETONIDE 0.025 % OINT.
    HYDROCORTISONE 2.5 % CRM/PE APP
    BETAMETHASONE DIPROPIONATE 0.05 % LOTION
    BETAMETHASONE VALERATE 0.1 % CREAM (G)
    BETAMETHASONE VALERATE 0.1 % LOTION
    TRIAMCINOLONE ACETONIDE 0.025 % LOTION
    FLUOCINOLONE ACETONIDE 0.025 % CREAM (G)
    FLUOCINOLONE ACETONIDE 0.025
    Class 6 – Low Potency
    TRIAMCINOLONE ACETONIDE 0.025 % CREAM
    FLUOCINOLONE ACETONIDE 0.01 % SOLUTION FLUOCINOLONE ACETONIDE 0.01 % OIL
    FLUOCINOLONE ACETONIDE 0.01 % CREAM (G)
    DESONIDE 0.05 % CREAM (G)
    DESONIDE 0.05 % LOTION

    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 June 13th, 2019 and last modified on June 14th, 2019.

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