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Date: February 13, 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
Business: Medi-Cal

Effective 04/20/2020, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

  1. Phentermine (Adipex-P) 15mg, 30mg, 37.5mg capsule: No restrictions.
  2. Nateglinide (Starlix) 120mg tablet: No restrictions.
  3. Netarsudil Mesylate (Rhopressa) 0.02% drops: No restrictions.
  4. Calcitriol (Rocaltrol) 0.5mcg capsule: No restrictions.
  5. Desloratadine (Clarinex) 5 mg tablet: No restrictions.
  6. Levocetirizine Dihydrochloride (Xyzal) 5 mg tablet: No restrictions.
  7. Beclomethasone (Beconase AQ) 42mcg nasal spray: No restrictions.
  8. Azelastine HCL (Astepro) 0.15% nasal spray: No restrictions.
  9. Ipratropium Bromide (Atrovent) 0.03%, 0.06% nasal spray: No restrictions.
  10. Fluticasone Propionate (Xhance) 93 mcg/spray: PA required. Reserved for Chronic Rhinosinusitis with Nasal Polyposis. Must have tried and failed sinus rinse plus steroid nasal sprays and nasal antihistamine for a minimum of 12 weeks.
  11. For Chronic Rhinosinutis – Dupilumab (Dupixent) 300 mg/2 ml syringe: PA required. Reserved for Chronic Rhinosinusitis with Nasal Polyposis with the supporting documentation/clinical findings such as nasal endoscopy or CT scan. Treatment failure/intolerance to Xhance x 12 weeks, in addition to saline nasal rinse, first line nasal steroid and nasal antihistamine sprays for 3 months with a history of or requiring surgery. Must be prescribed by a specialist.
  12. Generic Fluticasone/Salmeterol (Advair) 100 mcg/50 mcg, 250 mcg/50 mcg, 500 mcg/50 mcg Diskus: No restrictions.
  13. Iron Dextran Complex (Infed) 100 mg/2mL vial: No restrictions.

Formulary Status Changes:

  1. Sodium Bicarbonate 650mg tablet: No restrictions.
  2. Phentermine (Adipex-P) 37.5mg tablet: No restrictions.
  3. Specific Infant Formulas – Similac Expert Care Alimentum Powder, Similac Alimentum Powder; Enfamil Human Milk Fortifier Powder, Enfamil A.R. Powder, Enfamil Enfacare Powder and Liquid, Enfamil Neuro Enfacare Non-GMO Powder and Liquid; Pregestimil Powder; Similac Neosure Liquid, Similac Expert Care Neosure Powder, Similac PM 60-40 Powder; Neocate Infant DHA-ARA powder: Limited to persons less than 1 year of age.
  4. Collagenase (Santyl) 250 unit/G ointment: Limited to 90 grams per 30 days.
  5. Cyclosporine (Restasis) 0.05% eye emulsion
    • a. Unit Dose: Limited to 60 units per 30 days.
    • b. Multidose: Limited to 5.5 mL per 30 days.
  6. Sodium Polystyrene Sulfonate (SPS) powder for suspension: No restrictions.
  7. Voriconazole (Vfend) 200mg tablet; Linezolid (Zyvox) 600mg tablet; Posaconazole (Noxafil DR) 100mg tablet: Must be prescribed by Infectious Disease. Limited to 2 tablets per day.
  8. Cefazolin in Dextrose 1G/50mL, 2G/50mL Frozen Piggyback; Ceftriaxone in Dextrose 1G/50mL, 2G/50mL Frozen Piggyback: Limited to a 7-day supply at a time.
  9. Azelastine HCL (Astelin) 0.1% nasal spray: No restrictions.
  10. Fexofenadine HCL (Allegra) 180 mg Tablet: No restrictions. 
  11. Levalbuterol HCL (Xopenex) 0.31mg/3ml, 0.63mg/3ml, 1.25mg/3ml, 1.25mg/0.5mL Nebulizer Solution: Limited to 375 ml per 30 days.
  12. Levalbuterol Tartrate (Xopenex HFA) 45mcg aerosol solution: Limited to 2 inhalers per 30 days and 7 inhalers per 180 days.
  13. Tiotropium/Olodaterol (Stiolto Respimat) 2.5mcg-2.5mcg aerosol solution: Reserved for patient with at least Group B COPD confirmed by pulmonary function testing (PFTs). Limited to 1 inhaler per 30 days.
  14. Mepolizumab (Nucala) 100mg vial, 100 mg/ml Auto Injector, and Pre-filled syringes: PA required. Reserved for patients with poorly controlled, severe eosinophilic asthma with baseline serum eosinophil counts of either ≥ 150 cells/µL in the past 12 months AND 2 or more exacerbations in the past 12 months, despite being compliant with dose-optimized [1] Inhaled Corticosteroid (ICS) + Long-Acting beta-2 Agonist (LABA), [2] Spiriva Respimat, and [3] Leukotriene modifier or theophylline. Must be prescribed by an allergist. Limited to persons 6 years of age and older.

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 February 13th, 2020 and last modified on February 20th, 2020.