Provider Alerts

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Date:	June 14, 2016
To:	Health Plan of San Joaquin (HPSJ) Physicians and Providers
From:	Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject:	Formulary Update – Health Plan of San Joaquin (HPSJ) Physicians and Providers
Business:	Medi-Cal, AIM

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Effective by 8/16/2016, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Zepatier (Elbasvir/Grazoprevir): PA required Please see the Hepatitis C Coverage Policy that can be found at https://www.hpsj.com/medicationcoverage-policies/ for approval and formulary placement criteria.
2. Alli (Orlistat): PA required Reserved for patients with Body Mass Index > 35 OR > 30 with > 2 comorbidities AND have
   received exercise and dietary counseling at least twice by a registered dietitian.

Formulary Status/Requirement Changes:

1. Pradaxa (Dabigatran)Restricted to 60 capsules per month
   • a. 150 mg: No PA required
   • b. 75 mg: Remain non-formulary
2. Xarelto (Rivaroxaban)
   • a. 20 mg: No PA required
     – Restricted to 30 tablets per month
   • b. 15 mg: No PA required –
     Restricted to 42 tablets per three months
   • c. 10 mg: PA required – Reserved for post-TKA/THA DVT prophylaxis
3. Eliquis (Apixaban)
   1. a. 5 mg: No PA required
      Restricted to 74 tablets per month
   2. b. 2.5 mg: PA required
      Reserved for reduction of risk of recurrence of DVT/PE in patients who have had at least 6
      months of DVT/PE treatment, OR patients with atrial fibrillation who required renally
      dose-adjusted Apixaban as defined as any two of the following: Age ≥80 years, body
      weight ≤60 kg, or serum creatinine ≥1.5 mg/dL.
4. Brilinta (Ticagrelor)
   1. a. 90 mg: No PA required
      Restricted to 60 tablets per month
      Total concurrent Aspirin dose should not exceed 100 mg per day
   2. b. 60 mg: PA required
      Reserved for patients treatment experienced to 12 months of dual oral antiplatelet
      therapy with Clopidogrel, Ticagrelor, or Prasugrel
5. Effient (Prasugrel)
   1. a. 10 mg: PA required Reserved for patients status-post stent placement or medical management of ACS for patients intolerant of Clopidogrel or Ticagrelor, or who have concomitant Diabetes. Formulary Update June 14, 2016
   2. b. 5 mg: PA required For use in patients with weight or medical management of ACS for patients intolerant of Clopidogrel or Ticagrelor, or who have concomitant Diabetes.
6. Niacor/Niaspan (Nicotinic Acid): PA required.Restricted to patients with contraindication or intolerance to two formulary 1st line statins
   (despite step down approach).
7. Dextromethorphan solution/suspension/elixir products (e.g. Promethazine DM,
   Guaifenesin DM, etc.): Limited to 240 mL per fill; 7 fills per year
8. Codeine containing solution/suspension/elixir products (Guaifenesin/Codeine):
   Restricted to patients ≥12 years of ageLimited to 240 mL per fill; 4 fills per year
9. Xolair (Omalizumab): PA required
   1. a. Asthma – Reserved for patients with moderate to severe persistent asthma on dose
      optimized inhaled corticosteroids in combination with other controller medications. Must have documented pretreatment level IgE ≥30IU/ml and <700IU/ml, AND Positive
      skin test of in vitro reactivity to at least 1 perennial aeroallergen
   2. b. Chronic Idiopathic Urticara (CIU) – Reserved for patients with urticarial for longer than 6 weeks AND must have tried and failed monotherapy with a second generation nonsedating antihistamine up to four-fold the standard daily dose.

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Deletions from the Formulary:

The following products were removed from the formulary:

Drug	Formulary Alternatives	Grandfather members currently taking
Elspar (Asparaginase) 10,000 units	Erwinaze (Asparaginase) 10,000 unit vials	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.

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You may contact our Provider Services Department with any questions or concerns Monday through Friday, 8:00 am to 5:00 pm, at (209) 942-6340, or 1-888-936-PLAN (7526). Thank you for your continued support of Health Plan of San Joaquin.