Formulary Update – Effective November 30th, 2021

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Date: September 22
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 November 30th, 2021
Business: Medi-Cal Managed Care

Effective 11/30/2021, the Pharmacy and Therapeutics Committee has approved the following changes.

Additions to the Formulary

  1. Eluxadoline (Viberzi) 75 Mg, 100 Mg Tablet: PA required. For use in IBS-D: Step therapy for patients who have failed treatment with at least one tricyclic antidepressant (e.g. amitriptyline, nortriptyline) within their previous treatment history. Limited to 60 tablets per 30 days.
  2. Ofatumumab (Kesimpta) 20 Mg/0.4 Ml Pen: PA required. Reserved for adult patients with relapsing remitting multiple sclerosis, clinically isolated syndrome, or active secondary progressive disease who meet one of the following:
    1. Inadequate treatment response to one drug from the following two categories: [1] Betaseron / Avonex / Rebif / Glatopa, AND [2] Gilenya or Tecfidera. Must NOT have an active Hepatitis B infection and must have serum immunoglobulins screening prior to starting the first dose.
    2. Adult patient who is 40 years of age or younger, has had at least 1 relapse in the past 24 months, has an EDSS score of 3 or more, and diagnosed with multiple sclerosis for at least 5 years. Must NOT have an active Hepatitis B infection and must have serum immunoglobulins screening prior to starting the first dose. Must have a baseline gadolinium-enhanced MRI result.
      Loading Dose: Limited to 3 syringes for the first 28 days.
      Maintenance Dose: Limited to 1 syringe per 28 days following the loading dose. Must be seen by a neurologist. Restricted to specialty pharmacy.
  1. Diroximel Fumarate (Vumerity) 231 Mg Capsule: PA required. Reserved for patients with relapsing-remitting multiple sclerosis who have tried and failed or are intolerant to three months of compliant use of Tecfidera (dimethyl fumarate). Limited to 120 tablets per 30 days.
  2. Solriamfetol Hcl (Sunosi) 75 Mg, 150 Mg Tablet: PA required. Reserved for use in [1] excessive daytime sleepiness due to obstructive sleep apnea in patients who have tried and failed modafinil or [2] use in excessive daytime sleepiness due to narcolepsy in patients who have tried and failed modafinil AND a methyphenidate-based or amphetamine-based stimulant. Limited to 30 tablets per 30 days. Must be prescribed by a specialist.
  3. All Non-WIC Infant Formula Powders: Limited to less than 1 year of age.

Formulary Status Changes:

  1. Omega-3 Acid Ethyl Esters (Lovaza) 1 G Capsule: No Restrictions.
  2. Lidocaine (Lidoderm) 5 % Adh. Patch: Limited to 90 patches per 30 days.
  3. Ciclopirox (Ciclodan) 8 % Solution: No Restrictions.
  4. Midodrine Hcl 5 Mg Tablet: No Restrictions.
  5. Atorvastatin Calcium (Lipitor) 10 Mg, 20 Mg, 40 Mg, 80 Mg Tablet: No Restrictions.
  6. Albuterol Sulfate (Ventolin) 90 Mcg Hfa Inhaler: No Restrictions.
  7. Sacubitril/Valsartan (Entresto) 24-26 Mg, 49-51 Mg, 97-103 Mg Tablet: Limited to 60 tablets per 30 days.
  8. Tiotropium Bromide (Spiriva Respimat) 2.5 Mcg Mist Inhalation: No Restrictions.
  9. Sitagliptin Phosphate (Januvia) 100 Mg Tablet: No Restrictions.
  10. Metformin Hcl (Glucophage) 1000 Mg Tablet: No Restrictions.
  11. Semaglutide (Ozempic) 0.25 Or .5 Pen Injector, 1mg/0.75ml Pen Injector: No Restrictions.
  12. Lancing Device: No Restrictions.
  13. Icosapent Ethyl (Vascepa) 1 G Capsule: No Restrictions.
  14. Hydrocortisone (Procto-Med HC)2.5% Crm/Pe App: No Restrictions.
  15. Empagliflozin (Jardiance) 10 Mg, 25 Mg Tablet: No Restrictions.
  16. Amlodipine Besylate (Norvasc) 5 Mg, 10 Mg Tablet: No Restrictions.
  17. Dapagliflozin Propanediol (Farxiga) 10 Mg Tablet: No Restrictions.
  18. Rivaroxaban (Xarelto) 20 Mg Tablet: No Restrictions.
  19. Sodium, Potassium, Mag Sulfates (Suprep Bowel Prep Kit) 17.5-3.13g Solution Recon: No Restrictions.
  20. Linagliptin (Tradjenta) 5 Mg Tablet: No Restrictions.
  21. Dulaglutide (Trulicity) 0.75mg/0.5, 1.5 Mg/0.5 Pen Injector: No Restrictions.
  22. Tacrolimus (Protopic) 0.1 % Oint. (G): No Restrictions.
  23. Liraglutide (Victoza) 0.6 Mg/0.1 Pen Injector: No Restrictions.
  24. Insulin Aspart 100u/ml Insulin Pen (Novolog): No restrictions.
  25. Fora Glucose V10, V30 Test Strips : Limited to 200 per 30 days.
  26. Cimzia 200 Mg Vial Kit, 2×200 mg/ml Syringe Kit: PA required. Restricted to specialty pharmacy.
    • Third-line treatment for Psoriasis: Reserved for [1] treatment failure/documented intolerance to A) Adalimumab, Etanercept, or Infliximab and Secukinumab, Guselkumab, Brodalumab, Tildrakizumab, or Ixekizumab OR [2] women that are currently pregnant or breastfeeding. Must be prescribed by dermatologist. 
    • Second-line treatment for Rheumatoid Arthritis: reserved for treatment of rheumatoid arthritis and must meet one of the following: [1] treatment failure/documented intolerance to Adalimumab, Etanercept, Infliximab, Sarilumab, or Abatacept, OR [2] women that are currently pregnant or breastfeeding. Must be prescribed by a rheumatologist or dermatologist.
    • Second-line treatment for Crohn’s Disease: Reserved for treatment of Crohn’s disease and must meet one of the following: [1] Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathioprine, Mercaptopurine, Mesalamine, and Sulfasalazine) OR intolerance to corticosteroids OR [2] women that are currently pregnant or breastfeeding. Must be prescribed by a gastroenterologist.
  1. Vedolizumab (Entyvio): PA required. Reserved for treatment of Ulcerative Colitis or Crohn’s disease with treatment failure or intolerance to one TNF inhibitor for 2 months. Must be initiated by a gastroenterologist.
  2. Rifaximin (Xifaxan) 550 Mg Tablet: PA required.
    • For use in IBS-D: Reserved for patients who have failed treatment with at least one tricyclic antidepressant (e.g. amitriptyline, nortriptyline) for use in abdominal pain relief. Limited to 42 tablets per 14 days and 3 fills per 365 days.
  1. Vancomycin (Vancocin) 125 mg capsules: PA required. Reserved for Clostridium difficile infections as evidenced by C. diff toxin assay or C. diff DNA PCR.
  2. Fidaxomicin (Dificid) 200 Mg Tablet: PA required. Reserved for Clostridium difficile infections as evidenced by C. diff toxin assay or C. diff DNA PCR. Limited to 20 tablets per fill for initial or recurrent infections.

You may contact our Customer Service Department with any questions or concerns, Monday through Friday, 8:00 am to 5:00 pm, at 1-888-936-PLAN (7526), TDD/TYY 711.  Thank you for your continued support of Health Plan of San Joaquin.

Posted on September 22nd, 2021 and last modified on October 20th, 2021.

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