Provider Alerts

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Date:	May 17, 2018
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 July 23, 2018
Business:	Medi-Cal

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Effective 07/23/2018, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Alirocumab (Praluent): PA required. Reserved for patients who meet all of the following criteria:
1. Clinical ASCVD with LDL ≥70 mg/dL or non-HDL-C ≥ 100 mg/dL OR Heterozygous Familial Hypercholesterolemia (HeFH) with LDL > 100 mg/dL or non-HDL-C > 130 mg/dL.
2. Treatment failure to 12 weeks of ALL of the following:
1. A high intensity statin or maximally tolerated statin
2. Ezetimibe AND
3. Cholestyramine.
3. Triglycerides ≤ 200 mg/dL.
4. Prescribed by a cardiologist, endocrinologist, or lipid specialist.
5. For HeFH- must meet criteria for definite Familial Hypercholesterolemia according to (a) Simon- Broome, (b) Dutch Lipid Network or (c) US (MEDPED) diagnostic criteria.
6. Limited to 2 injections per 28 days per strength.
7. Restricted to Specialty Pharmacy.
2. Evolocumab (Repatha): PA required. Reserved for patients who meet all of the following criteria:
1. Clinical ASCVD with LDL ≥70 mg/dL or non-HDL-C ≥ 100 mg/dL OR Heterozygous Familial Hypercholesterolemia (HeFH) with LDL > 100 mg/dL or non-HDL-C > 130 mg/dL OR Homozygous Familial Hypercholesterolemia (HoFH) with LDL >300 mg/dL or non-HDL-C > 330 mg/dL
2. Treatment failure to 12 weeks of ALL of the following:
   1. High intensity statin or maximally tolerated statin
   2. Ezetimibe AND
   3. Cholestyramine.
3. Triglycerides ≤ 200 mg/dL.
4. Prescribed by a cardiologist, endocrinologist, or lipid specialist.
5. For HeFH patients-must meet criteria for definite Familial Hypercholesterolemia according to (a) Simon-Broome, (B) Dutch Lipid Network or (C) US (MEDPED) diagnostic criteria.
6. For HoFH patient’s genetic testing is required and PCSK9 inhibitors are not covered in patients with two LDL receptor negative alleles.
7. Repatha 140mg/ml – Limited to 2 injections per 28 days.
8. Repatha Pushtronex System 420mg/3.5ml – Limited to 1 injection per 28 days.
9. Restricted to Specialty Pharmacy.
3. Beclomethasone (Qvar) Rediclick: Limited to 1 package per 30 days.

Formulary Status Changes:

1. Testosterone 1% Gel Packets, Gel Pump, Gel: Reserved for patients who meet BOTH of the following criteria:
1. Treatment failure to or inability to administer intramuscular testosterone injections patients AND
2. Undergoing Gender Transition OR having documentation of hypogonadism as evidenced by testosterone levels below 300ng/dL confirmed on two separate occasions with levels drawn before 10:00am.
2. Bosentan (Tracleer): PA required. Reserved for patients who meet all of the following criteria:
1. Treatment failure to Ambrisentan or Macitentan
2. Prescribed by a Cardiologist, Pulmonologist, or Critical care
3. Diagnosis of Pulmonary Artery Hypertension, WHO GROUP I
4. WHO Functional Class (WHO FC) II-IV
5. Right Heart Catheterization with Vasoreactivity test
3. Rosuvastatin (Crestor): Limited to 30 tablets per 30 days of any strength.
4. Ezetimibe (Zetia): Reserved for patients who meet one of the following criteria:
1. Concurrently on a high intensity statin,
2. Concurrently on a maximally tolerated statin with ASCVD risk, OR
3. Has contraindication/intolerance to three (3) formulary 1st line statins, two of which must be hydrophilic statins (Rosuvastatin, Pravastatin).
5. Podofilox (Condylox) 5% Gel: PA required. Reserved for use in perianal warts only.
6. Rifapentine (Priftin): Limited to 128 tablets per 180 days.
7. FDA Drug Safety Communication 1/11/18: Prescription cough and cold medicines containing codeine and hydrocodone are contraindicated in patients <18 years due to risks of misuse, abuse, addiction, overdose, death, and slowed or difficult breathing. As a result, HPSJ is making the following changes:
   1. Codeine containing cough syrups (e.g. Promethazine-codeine, Guaifenesin-codeine):
1. Increased age limit to 18 years of age and older.
2. Limited to 240mL per fill and 4 fills per 365 days.
1. Hydrocodone Bitartrate/Homoatropine Syrup:
1. Increased age limit to 18 years of age and older.
2. Limited to 240mL per fill and 4 fills per 365 days.

Deletions from the Formulary:

The following products will be removed from the formulary as of July 23, 2018:

Drug	Formulary Alternatives	Grandfather members currently taking
Diltiazem 360mg 24 HR CD Capsules	Two Diltiazem 180mg 24 HR CD Capsules	No
Diltiazem 360mg 24 HR ER Capsules	Two Diltiazem 180mg 24 HR ER Capsules	No
Orenitram ER tablets – all strengths	Remodulin, Tyvaso	Yes
Tadalafil (Adcirca)	Sildenafil 20mg tablets (Revatio)	Yes

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.