Provider Alerts

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Date:	February 27, 2018
To:	Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies
From:	Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject:	Formulary Update – The Pharmacy and Therapeutics Committee has approved the following changes
Business:	Medi-Cal

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Effective 05/02/2018, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Sarilumab (Kevzara) for Rheumatoid Arthritis: a. PA Required. Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine, Azathioprine). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Restricted to Diplomat Specialty Pharmacy.
2. Infliximab-dyyb (Inflectra), Infliximab-abda (Renflexis):
   1. Rheumatoid Arthritis, Psoriasis, Psoriatic Arthritis, Chronic Bowel Disease: Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy. If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Restricted to Diplomat Specialty Pharmacy.
   2. Anklyosing Spondylitis: Reserved for documented symptomatic AS despite treatment with NSAIDs (unless NSAID-intolerant). An adequate trial is defined as at least 2 different NSAIDs tried over 1 month or 2 different NSAIDs over 2 months.
3. Clobetasol 0.05% Shampoo: Limited to 118 mL per 90 days.
4. Clobetasol 0.05% Gel: Limited to 60 grams per 90 days.
5. Betamethasone Dipropionate 0.05% Lotion: Limited to 60 grams per 90 days.
6. Halobetasol Propionate 0.05% Ointment/Cream: Limited to 60 grams per 90 days.
7. Fluocinonide-E 0.05% Cream: No restrictions.
8. Guselkumab (Tremfya), Brodalumab (Siliq) for Psoriasis: PA required. Reserved for treatment failure/documented intolerance to Adalimumab, Etanercept, or Infliximab. Must be prescribed by dermatologist. Restricted to Diplomat Specialty Pharmacy.
9. Ixekizumab (Taltz) for Psoriatic Arthritis: PA required. Reserved for treatment failure/documented intolerance to two 1st line agents (Adalimumab, Etanercept, or Infliximab) OR one 1st line agent (Adalimumab, Etanercept, Infliximab) and one 2nd line agent (Abatacept, Certolizumab, Golimumab, Secukinumab). Must be prescribed by rheumatologist or dermatologist. Restricted to Diplomat Specialty Pharmacy.
10. Mesalamine 1.2mg DR Tablets (Lialda): Reserved for treatment failure of balsalazide, sulfasalazine, or mesalamine enema for 3 months for induction or maintenance.
11. Mesalamine 0.375mg SR Capsules (Apriso): Reserved for treatment failure of balsalazide, sulfasalazine, or mesalamine enema for 3 months for induction or maintenance. Restricted to 120 capsules per 30 days, 6 fills per 180 days.
12. Mesalamine 800 mg DR Tablets (Asacol HD): Reserved for treatment failure of balsalazide, sulfasalazine, or mesalamine enema for 3 months for induction or maintenance. Restricted to 252 tablets per 180 days.
13. Recombinant Zoster Vaccine (Shingrix): Restricted to patients age ≥50 years old.
14. Eszopiclone 1mg, 2mg, 3mg tablets (Lunesta): Limited to 60 tablets per 75 days.
15. Cabergoline 0.5mg Tablets: Limited to 8 tablets per 30 days.
16. Methylergonovine 0.2mg Tablets (Methergine): Limited to 28 tablets per 365 days.
17. Lipase/Protease/Amylase DR 40K Unit Capsule (Zenpep): No restrictions.
18. Levonorgestrel/Ethinyl Estradiol 0.15/0.03mcg tablets (Lillow): No restrictions.

Formulary Status Changes:

1. Clobetasol 0.05% Ointment (Embeline)/Cream (Cormax): Step therapy to treatment failure, contraindication, or intolerance to a formulary Super High Potency (Class 1) topical steroid. Limited to 60 grams per 90 days.
2. Betamethasone Valerate 0.1% Ointment (Luxiq), Fluocinonide 0.05% Cream (Lidex): Step therapy to treatment failure, contraindication, or intolerance to a formulary Medium-High Potency (Class 3) topical steroid.
3. Mometasone Furoate 0.1% Ointment (Elocon)/Cream (Elecon), Fluocinolone 0.025% Ointment (Synalar): Step therapy to treatment failure, contraindication, or intolerance to a formulary Medium Potency (Class 4) topical steroid.
4. Desonide 0.05% Ointment (Desowen): Step therapy to treatment failure, contraindication, or intolerance to a formulary Low-Medium Potency (Class 5) topical steroid.
5. Fluocinolone 0.01% Cream (Synalar), Desonide 0.05% Cream (Desowen): Step therapy to treatment failure, contraindication, or intolerance to a formulary Low Potency (Class 6) topical steroid.
6. Abatacept (Orencia), Secukinumab (Cosentyx) for Psoriatic Arthritis: PA required. Reserved for treatment failure/documented intolerance to Adalimumab, Etanercept, or Infliximab. Must be prescribed by rheumatologist or dermatologist. Restricted to Diplomat Specialty Pharmacy.
7. Linaclotide (Linzess): PA required. Linzess is reserved for patients with treatment failure of properly titrated and regularly scheduled dosing of polyethylene glycol for 2 months (as evidenced by prescription history fills) AND two of the following: bisacodyl, Senna, psyllium, lactulose, magnesium citrate or hydroxide. Limited to 30 capsules per 30 days.
8. Hyoscyamine 0.125mg/mL Drops: Restricted for use in children and infants <2 years old only.
9. Rifaxamin 550mg tablets (Xifaxan):
   1. For use in Hepatic encephalopathy, Xifaxan is reserved for treatment failure of compliant use of lactulose evidenced by consistent lactulose fills.
   2. For use in IBS-D, Xifaxan is reserved for patients who have failed treatment with at least one antispasmodic, one TCA, and loperamide; or failed treatment with at least one antispasmodic and one TCA for use in abdominal pain relief. Limited to 42 tablets per 14 days and 3 fills per 365 days.
10. Live/Attenuated Zoster Vaccine (Zostavax): Restricted to patients age ≥50 years old.
11. Malathion 0.5% Lotion (Ovide): Step therapy to treatment failure of at least 2 (two) documented treatment courses of permethrin in the last 30 days. Limited to 118mL per 30 days.

Deletions from the Formulary:
The following products will be removed from the formulary as of May 02, 2018:

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 Services Department with any questions or concerns Monday through Friday 8 a.m. to 6 p.m. at (209) 942-6300 or 1-888-936-PLAN (7526). Thank you for your continued support of Health Plan of San Joaquin.