Provider Alerts

---

Date:	December 12, 2019
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 February 24, 2020
Business:	Medi-Cal

---

Effective 02/24/2020, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Tranexamic Acid (Lysteda) 650 mg tablet: No restrictions.
2. Ethinyl estradiol/Norethindrone acetate (Lo Loestrin FE) 0.01mg/1mg tablet: Limited to 13 cycles per year.
3. Drospirenone/Ethinyl Estradiol (Loryna, Nikki, Vestura) 3mg/20mcg tablet: Limited to 13 cycles per year.
4. Drospirenone/Ethinyl Estradiol (Syeda, Zarah) 3mg/30mcg tablet: Limited to 13 cycles per year.
5. Ciclopirox (Loprox, Ciclodan, Penlac), 0.77% Gel/Cream/Topical Suspension: PA required. Must have completed oral Terbinafine treatment for 6 weeks for fingernail or 12 week treatment for toenail Onychomycosis. For other Tinea infections, must have tried and failed first line agents within the last 2 months. 
6. Penicillin G Procaine 600,000 unit/1mL: No restrictions.
7. Ceftriaxone 250mg, 500mg, 1gm injection: Fill limit of 1 per 365 days.
8. Hydrocortisone sodium succinate (Solu-CORTEF) 100mg vial: No restrictions.
9. Oxiconazole (Oxistat) 1% cream: No restrictions.
10. Valbenazine (Ingrezza) 40mg, 80mg capsule; Deutetrabenazine (Austedo) 6mg, 9mg, 12mg tablet: PA required. Limited to persons ≥ 18 years of age. Restricted to specialty pharmacy. Must meet all of the following criteria:
    1. Must have a documented diagnosis of moderate to severe tardive dyskinesia according to DSM V criteria for at least 3 months.
    2. Must have an Abnormal Involuntary Movement Scale ≥ 6.
    3. No active diagnosis of suicidal ideation within 6 months.
    4. Quantity limits:
       1. Ingrezza: Limited to 30 tablets per 30 days.
       2. Austedo: Limited to 60 tablets per 30 days.

Formulary Status Changes:

1. Sevelamer HCL (Renagel) 800 mg tablet: Step therapy to treatment failure or documented intolerance to Sevelamer Carbonate.
2. Celecoxib (Celebrex) 50mg, 100mg, 200mg, 400mg capsule: No restrictions.
3. Pregabalin (Lyrica):
   1. 25mg, 50mg, 75mg, 100mg, 150mg, 200mg capsule: Limited to 90 capsules per 30 days.
   2. 225mg, 300mg capsule: Limited to 60 capsules per 30 days.
4. Micronized Progesterone (Prometrium) 100mg, 200mg capsule: PA required. Reserved for women with history of preterm birth, short cervix (< 25 mm), history of 2 miscarriages, or for the prevention of endometrial hyperplasia in postmenopausal women with a uterus who are receiving conjugated estrogen. Limited to 2 capsules per day.
5. Erenumab (Aimovig) 70mg/mL, 140mg/mL auto-injector; Fremanezumab (Ajovy) 225mg/1.5mL syringe; Galcanezumab (Emgality) 120mg/mL auto-injector/syringe: PA required. Limited to persons ≥ 18 years of age. Reserved for patients intolerant to or have tried 12 months of therapy with Botox. 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.
6. Voriconazole (Vfend) 200mg tablet: PA required. Restricted to treatment failure of fluconazole for candidiasis.
7. Oxybutynin ER (Ditropan LA) 5mg, 10mg, 15mg tablet: Limited to 30 tablets per 30 days.
8. Trospium IR (Sanctura) 20mg tablet: Limited to 60 tablets per 30 days.
9. Trospium ER (Sanctura XR) 60mg capsule: Limited to 30 capsules per 30 days.
10. Fesoterodine (Toviaz) 4 mg, 8 mg tablet; Solifenacin (Vesicare) 5 mg, 10 mg tablet: Step therapy to at least one first line anti-muscarinic agent (Oxybutynin IR/ER or Trospium IR/ER) in the last 30 days. Limited to 30 capsules per 30 days.
11. Mirabegron (Myrbetriq) 25mg, 50mg tablet: PA required. Reserved for treatment failure or intolerance to at least two anti-muscarinic agents for overactive bladder use in the last 365 days.
12. Fenofibrate 54mg tablet, 67mg capsule, 134mg capsule, 160mg tablet, 200mg capsule: No restrictions.

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.