Provider Alerts

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Date:	December 14, 2017
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

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Effective 02/22/2018, the Pharmacy and Therapeutics Committee has approved the following changes:

1. Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi): PA required. This medication is restricted to Diplomat Specialty Pharmacy. Please see the Hepatitis C Coverage Policy for preferred regimens. The AASLD guidelines were updated on 9/21/17. 2.
2. Glecaprevir/Pibrentasvir (Mavyret): PA required. This medication is restricted to Diplomat Specialty Pharmacy. Please see the Hepatitis C Coverage Policy for preferred regimens. The AASLD guidelines were updated on 9/21/17.
3. Ocrelizumab (Ocrevus): PA required. Patient must have chart notes showing a diagnosis of Multiple Sclerosis and prescription must be written by a neurologist. For patients with Primary Progressive Multiple Sclerosis (PPMS), this will be considered a first line agent. For diagnosis of Relapsing MS (RMS), patients must have documented treatment failure of one drug from the following two categories: [1] Betaseron / Avonex / Rebif / Glatopa, AND [2] Gilenya or Aubagio. Documentation that the member is negative for latent or active infections is also required.
4. Glatiramer acetate (generic Copaxone) 20mg/ml, 40mg/ml: PA required. Restricted to patients with a verified diagnosis of multiple sclerosis (MS) with therapy initiated by a neurologist. This medication is restricted to Diplomat Specialty Pharmacy.
5. Fluticasone Propionate/Salmeterol (generic AirDuo Respiclick): Limited to 1 inhaler per 30 days.
6. Fluticasone Furoate/Vilanterol (Breo Ellipta): Limited to 1 inhaler per 30 days.
7. Fluticasone Furoate/Umeclidinium/Vilanterol (Trelegy): PA required. Reserved for patients with confirmed diagnosis of COPD and are GOLD Group D who are compliant with Breo Ellipta. Exacerbation history and the patient’s mMRC and/or CAT score within the past year is also required. Limited to 1 inhaler per 30 days.
8. Diazepam 2.5 mg, 10 mg, 20 mg rectal gel: Limited to 1 kit per 30 days.
9. Levonorgestrel-ethinyl estradiol (Larissia) 0.1-0.02 mg tablet: No restrictions.
10. Respironics Innospire: Limited to 1 nebulizer per lifetime.
11. Linaclotide (Linzess) 72 mcg tablet: PA required. Linzess is reserved for treatment failure of properly titrated and regularly scheduled dosing of polyethylene glycol for 2 months and 2 other laxatives.
12. Shingrix vaccine: Restricted to patients ≥50 years of age. Limited to 2 fills per lifetime.

Formulary Status Changes:

1. Tiotropium Bromide (Spiriva/Spiriva Respimat 2.5mcg), Aclidinium Bromide (Tudorza Pressair): PA required. Reserved for patients with COPD confirmed by PFTs and are GOLD Group B or higher. Limited to 1 package per 30 days.
2. Roflumilast (Daliresp): PA required. Reserved for patients in GOLD Group D who are compliant with, or intolerant to, use of [1] Long acting anticholinergics (Spiriva) AND [2] either ICS (Qvar/Flovent/Arnuity Ellipta/Pulmicort) + Long acting beta agonists (Serevent/Foradil) or ICS/LABA combination (Advair/Symbicort/Dulera/Breo Ellipta ).
3. Rivaroxaban (Xarelto) 10 mg tablet: Limited to 35 tablets per 365 days.
4. Apixaban (Eliquis) 2.5 mg tablet: Limited to 70 tablets per 365 days.
5. Sevelamer Hcl (Renagel): PA required. Reserved for treatment failure or intolerance to Sevelamer Carbonate (Renvela).
6. Patiromer (Veltassa): PA required. Reserved for patients with Potassium >5.5 mEq/L AND one of the following: at risk of colonic necrosis (impaction, chronic constipation, inflammatory bowel disease, ischemic colitis, vascular intestinal atherosclerosis, or bowel obstruction), OR Hypernatremia, OR Diagnosis of Heart Failure. Limited to 1 packet per day.
7. Spinosad (Natroba): Step therapy to treatment failure of at least 2 (two) documented treatment courses of permethrin 1% lotion in the last 30 days.
8. Benzyl Alcohol (Ulesfia): PA required. Reserved for treatment failure of Spinosad (Natroba) AND Malathion (Ovide) in the last 30 days.

Deletions from the Formulary: The following products will be removed from the formulary as of February 22, 2018:

Drug	Formulary Alternatives	Grandfather members currently taking
Copaxone 20mg/ml; 40mg/ml	Generic Glatiramer acetate 20mg/ml; 40mg/ml	No
Advair HFA; Advair Diskus	Symbicort, Generic AirDuo Respiclick, Dulera, Qvar with Spacer	No
Montelukast 4 mg granule packets	Crushed Montelukast 4 mg chewable tablets	No
Naproxen 125 mg/5 ml oral suspension	Ibuprofen chewable tablets, Ibuprofen suspension, Ibuprofen oral drops, Indomethacin rectal suppository	No
Indomethacin 25 mg/5 ml oral suspension	Ibuprofen chewable tablets, Ibuprofen suspension, Ibuprofen oral drops, Indomethacin rectal suppository	No
Captopril/HCTZ tablets	Lisinopril/HCTZ, Benazepril/HCTZ, Enalapril/HCTZ	No
Ivermectin 0.5% Lotion (Sklice)	Permethrin 1% Lotion (Nix) , Malathion 0.5% Lotion (Ovide), Spinosad 0.9% Suspension(Natroba)	No
Methylphenidate 5mg/5mL solution	Methylphenidate 10mg/5mL Solution	No

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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.