Provider Alerts - February 25, 2019

Formulary Update for 4/29/2019

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Date: February 25, 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 for 4/29/2019
Business: Medi-Cal

Effective 4/29/19, the Pharmacy and Therapeutics Committee has approved the following changes:
 
Additions to the Formulary:

  1. Fidaxomicin (Dificid) 200mg Tablet:  PA required.   Reserved for treatment failure to recurrent episodes of C. difficile that has been treated with one standard 10 day course of oral Vancomycin AND a tapered/pulsed dose course of oral Vancomycin for at least 6 weeks. Positive (detected) C. difficile toxin on assay or DNA PCR is required.  Limited to 20 tablets per 10 days. 
  2. Bezlotoxumab (Zinplava) 1000mg/40 ml vial:  PA required.   Reserved for patients who meet ALL of the following criteria: 
    1. Positive (detected) C. difficile toxin on assay or DNA PCR; 
    2. Currently receiving standard of care antibiotic therapy for C. difficile; 
    3. High risk of C. difficile infection recurrence meeting any of the following: 
      1. Individual 65 years of age or older, with a history of C. difficile infection (CDI) in the past 6 months;
      2. Immunocompromised state (eg. active hematologic malignancy, prior solid organ transplant, AIDS/immunodeficient condition, etc.);  iii. Clinically severe CDI (as defined by a Zar score of greater than or equal to 2); or  iv. C. difficile ribotypes 027, 078, 244.
  3. Epoetin alfa-epbx (Retacrit) Vial:  PA required.  Reserved for patients who have Hemoglobin (Hgb) < 9 g/dl with TSAT > 20% and serum ferritin > 100 ng/ml at initiation. 
  4. Fluticasone Propionate OTC:  No restrictions.

 Formulary Status Changes:

  1. Colchicine (Colcrys): Step therapy to allopurinol filled within the last 30 days.  Limited to 61 tablets per 30 days and 6 fills per 365 days.
  2. Methylphenidate IR Chewable Tablet: PA required.   Reserved for documented inability to take methylphenidate IR solution by mouth. Limited to persons ≥ 4 years of age. 
  3. Methylphenidate ER (Quillichew) Tablet/ Quillivant XR Suspension: PA required. Reserved for documented inability to take methylphenidate ER capsules by mouth with or without applesauce. Limited to persons ≥ 4 years of age.
  4. Methylphenidate Patch (Daytrana): PA required. Reserved for patients with documented inability to swallow tablets, capsules, chewables, solutions, or suspensions.  Limited to persons ≥ 4 years of age.
  5. Lisdexamfetamine Dimesylate (Vyvanse) Capsule:  PA required. Reserved for documentation of treatment failure or intolerance to one Methylphenidate ER-based and one Amphetamine ERbased stimulant medication.  Limited to persons ≥ 4 years of age.
  6. Methylphenidate ER capsules, Dextroamphetamine/Amphetamine ER capsules, Dextroamphetamine ER capsules: Limited to persons ≥ 4 years of age.
  7. Methylphenidate ER tablets, Dexmethylphenidate ER capsules: Step therapy to at least one ER tier 1 formulary stimulant medication within the last 120 days. Limited to persons ≥ 4 years of age.
  8. Epoetin Alfa (Procrit) Vial:  PA required.  Reserved for patients who have Hemoglobin (Hgb) < 9 g/dl with TSAT > 20% and serum ferritin > 100 ng/ml at initiation AND have treatment failure or intolerance to Epogen. 
  9. Levalbuterol (Xopenex): PA required.  Reserved for intolerance to albuterol. Limited to 7 inhalers per 180 days, 2 inhalers per 30 days. 
  10. Fluticasone Furoate/Umeclidinium/Vilanterol (Trelegy Ellipta) Inhalation Powder: PA required.   Reserved for patients with COPD GOLD grade 3 or 4, Group D with compliant use of ICS+LABA or LABA+LAMA in the prior 12 weeks.  Limited to 1 Inhaler per 30 days.
  11. Roflumilast (Daliresp) Tablet:  PA required.   Reserved for patients with GOLD Grade 4, Group D who have failed treatment or are intolerant to high dose ICS+LABA+LAMA in the past 12 weeks.  
    1. Daliresp 250 mcg tablets: Limited to 30 tablets per 365 days.  
    2. Daliresp 500 mcg tablets: Limited to 30 tablets per 30 days. 
  12. Dupilumab (Dupixent) Syringe:  PA required.  Must be prescribed by an allergist or pulmonologist.  Criteria for atopic dermatitis still remains as well.
    1. Eosinophilic asthma: Reserved as add on therapy for patients 12 years and older with moderate to severe asthma meeting ALL of the following criteria:
      1. Pretreatment eosinophil level ≥ 150 cells/µL;
      2. Tried and failed or intolerance to compliant use of high dose ICS plus LAMA+LABA+LTRA for at least 3 months; iii. ≥ 2 exacerbations requiring systemic corticosteroids for ≥ 3 days or hospitalization or ER requiring systemic corticosteroids while on high dose ICS plus LAMA+LABA+LTRA.
    2. Oral corticosteroid dependent asthma: Reserved as add on therapy for patients 12 years and older who are dependent on oral steroids meeting ALL of the following criteria:
      1. Minimal dose of 5 mg Prednisone per day or equivalent dose for 6 months;
      2. Tried and failed or has intolerance to compliant use of ICS plus 2 controller medications for at least 3 months; iii. Treatment plan is to reduce or completely eliminate oral corticosteroid use.
  13. Flunisolide Nasal Spray:  Step therapy to an adequate trial (7-14 days) of any 2 (two) first-line agents (fluticasone, budesonide, triamcinolone).
  14. Beclomethasone Dipropionate (Qnasl):  Step therapy to an adequate trial (7-14 days) of any 2 (two) first-line agents (fluticasone, budesonide, triamcinolone) AND flunisolide.  
  15. Mometasone Furoate Spray (Nasonex): Step therapy to an adequate trial (7-14 days) of any 2 (two) first-line agents (fluticasone, budesonide, triamcinolone) AND flunisolide.
  16. Ranitidine 150mg, 300mg Capsules:  PA required.  Reserved for patients who have tried and failed treatment with Ranitidine tablets.
  17. Sacubitril/Valsartan (Entresto): PA required. Reserved for patients who meet ALL of the following criteria:
    1. LVEF ≤40%;
    2. Currently on dose optimized or maximally tolerated doses of all of the following: Beta blockers, ACE-I or ARB, and Aldosterone Antagonist;
    3. An ARB must be tried if an ACE-I cannot be tolerated due to cough.

Deletions from the Formulary:
The following products will be removed from the formulary as of April 29, 2019:

Drug

Formulary Alternatives

Grandfather members
currently taking 

Ventolin HFA (brand)

Albuterol HFA (generic)

No

Isosorbide Dinitrate (Dilatrate) SR 40mg capsules

Isosorbide Dinitrate ER 40mg tablets

No

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.

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