Formulary Update – Effective December 16, 2020

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Date: October 8, 2020
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 December 16, 2020
Business: Medi-Cal

Effective December 16, 2020, the Pharmacy and Therapeutics Committee has approved the following changes.

Additions to the Formulary:

  1. Upadacitinib (Rinvoq) 15mg ER tablets: PA required. Reserved for treatment of rheumatoid arthritis with treatment failure or contraindications to Baricitinib. Must be initiated by a rheumatologist. Restricted to specialty pharmacy. Limited to 30 tablets per 30 days.
  2. Tetracycline 500mg capsules: PA required. Reserved for patients with a positive Helicobacter pylori infection. Limited to 56 capsules per 14 days.
  3. Etanercept (Enbrel) 50mg/ml Mini Cartridge: 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 prescribed by a specialist.
  4. Romosozumab-AQQG (Evenity) 105mg/1.17ml syringe: PA required. Reserved for treatment failure to bisphosphonate with calcium therapy, defined as progression of bone loss or fracture occurring while on therapy OR intolerance to 2 formulary bisphosphonates. Limited to 2 pens (1.17ml each) per 30 days. Limited to 12 total months of treatment. Restricted to specialty pharmacy.
  5. All oncology agents, including those newly FDA approved (both pharmacy and medical benefit): PA required. Approval is determined by medical necessity.

Formulary Status Changes:

  1. Xarelto 2.5mg tablets: PA required. Reserved for patients with stable CAD or patients with symptomatic PAD with high risk of cardiovascular events. Documentation of inadequate response/intolerance to dual antiplatelet therapy is required unless not indicated (refer to 2016 ACC/AHA guidelines update on Duration of DAPT in CAD patients). Must have a mandatory bleeding risk assessment. Expected benefit must outweigh the bleeding and associated risks.  Must be prescribed by a cardiologist.
  2. For Psoriasis – Ixekizumab (Taltz) 80mg/ml autoinjector, syringe: PA required. Reserved for treatment failure/documented intolerance to Adalimumab, Etanercept, or Infliximab. Must be prescribed by a dermatologist. Restricted to specialty pharmacy.
  3. For Rheumatoid Arthritis:
    1. Baricitinib (Olumiant) 2mg tablet: PA required.Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine, Azathioprine). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Must be prescribed by Rheumatologist. Restricted to specialty pharmacy.
    2. Tofacitinib (Xeljanz) 5mg, 11mg (XR): PA required. Reserved for treatment of rheumatoid arthritis with treatment failure or contraindications to Baricitinib. Must be initiated by a rheumatologist. Restricted to specialty pharmacy.
      1. Xeljanz 5mg tablets: Limited to 60 tablets per 30 days.
      2. Xeljanz 11mg XR tablets: Limited to 30 tablets per 30 days.
  4. Epoetin Alfa (Epogen) 2,000U/ml, 3,000U/ml, 4,000U/ml, 10,000U/ml, 20,000U/ml and 20,000U/2ml vials: PA required. Reserved for patients who have Hemoglobin (Hgb) < 10 g/dl with TSAT > 20% and serum ferritin > 100 ng/ml at initiation AND treatment failure or contraindication to Retacrit. Restricted to specialty pharmacy.
  5. Epoetin Alfa-EPBX (Retacrit) 2,000U/ml, 3,000U/ml, 4,000U/ml, 10,000U/ml, 40,000U/ml vials: PA required. Reserved for patients who have Hemoglobin (Hgb) < 10 g/dl with TSAT > 20% and serum ferritin > 100 ng/ml at initiation. For renewal, Hgb must be below 11 g/dL. Restricted to specialty pharmacy.
  6. Abaloparatide (Tymlos) 3,120mcg/1.56ml pen injector: PA required. Reserved for any of the following: [1] treatment failure to bisphosphonate with calcium therapy, defined as progression of bone loss or fracture occurring while on therapy; [2] intolerance to 2 formulary bisphosphonates; or [3] patients with a T-score of the spine of less than or equal to -3.0 with back pain. Limited to 1 pen (1.56ml) per 30 days. Limited to 24 total months of treatment. Restricted to specialty pharmacy.
  7. Teriparatide (Bonsity) 620mcg/2.48ml pen: PA required. Reserved for treatment of osteoporosis as evidenced by documented T-score <-2.5 in patients with treatment failure or intolerance to Abaloparatide. Limited to 1 pen (2.4ml) per 28 days. Limited to 24 total months of treatment. Restricted to specialty pharmacy.
  8. Denosumab (Prolia) 60mg/ml syringe: PA required. Reserved for treatment failure to bisphosphonate with calcium therapy, defined as progression of bone loss or fracture occurring while on therapy OR intolerance to 2 formulary bisphosphonates. Limited to 1 fill per 180 days. Restricted to specialty pharmacy.
  9. Zoledronic Acid (Reclast) 5mg/100ml IV solution: Restricted to 1 fill per 365 days.
  10. Risedronate (Actonel) 5mg, 35mg, 150mg tablets: Step therapy to an adequate trial or intolerance to alendronate.
    • 150mg tablet restricted to 1 tablet per month
    • 35mg tablets restricted to 4 tablets per month
    • 5mg tablet restricted to 30 tablets per month
    • Risedronate 30mg tablets: PA required. Reserved for treatment failure or intolerance to alendronate for use in Paget’s Disease. Limited to 30 tablets per month.                            

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 October 8th, 2020 and last modified on October 8th, 2020.

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