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Formulary Update

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Date: September 21, 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
Products: Medi-Cal

Effective 11/29/2017, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

  1. Rizatriptan 5mg ODT: Limited to 9 tablets per 30 days. For frequent headaches >2 per month, prophylaxis with Topamax, Depakote, or beta blockers may be considered.
  2. Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi): PA required. This medication is restricted to Diplomat Specialty Pharmacy. Please see the Hepatitis C Coverage Policy for preferred regimens pending AASLD guidelines update.
  3. Glecaprevir/Pibrentasvir (Mavyret): PA required. This medication is restricted to Diplomat Specialty Pharmacy. Please see the Hepatitis C Coverage Policy for preferred regimens pending
    AASLD guidelines update.
  4. Basaglar U-100 Kwikpen (Insulin Glargine): Limit 1 box per 60 days.
  5. Humulin R U-500 Kwikpen: PA required. Reserved for patients requiring more than 200 units of
    insulin per day.
  6. Bydureon Pen Injector: PA required. Reserved for an inadequate response to an adequate trial of
    Metformin (unless intolerant or contraindicated) for patients with HbA1c < 9% AND who have
    failed Victoza. A trial of Metformin ER is required if intolerance is GI-related.
  7. Synjardy (Empagliflozin/Metformin) 5mg-500mg, 5mg-1000mg, 12.5mg-500mg, 12.5mg-
    1000mg tablets: Limited to 60 tablets per 30 days.
  8. Synjardy XR:

a. 5mg-1000mg tablets, 12.5mg-1000mg tablets: Limited to 60 tablets per 30 days.
b. 10mg-1000mg tablets, 25mg-1000mg tablets: Limited to 30 tablets per 30 days.

  1. Restasis 0.05% multi-dose 5.5 ml. PA required. Reserved for patients who have failed ophthalmic lubricants in the last 6 months.
  2. Peg 400/Hypromellose/Glycerin (1-0.2-0.2%) drops: No restrictions.
  3. Carboxymethylcellulose Sodium (0.5%) dropperettes: No restrictions.
  4. Carboxymethylcellulose Sodium (0.5%) Drops: No restrictions.
  5. Propylene Glycol/Peg 400/Pf (0.3-0.4%) dropperettes: No restrictions.
  6. Hypromellose (0.3%) drops: No restrictions.
  7. Carboxymethylcellulose/Glycerin (0.5-0.9%) drops: No restrictions.

Formulary Status Changes:

  1. Sumatriptan 5mg, 20mg Nasal Spray: PA required. Reserved for patients ≥12 years of age and
    unable to take oral meds (including ODT). Limited to 6 actuations per 30 days.
  2. Butalbital 50mg – Acetaminophen 325mg – Caffeine 40mg – Codeine 30mg Capsules:
    Restricted to patients ≥12 years of age. Limited to 30 capsules per 30 days.
  3. Naratriptan 1mg, 2.5mg Tablets: Naratriptan is step therapy to treatment failure of Imitrex OR
    Maxalt. For frequent headaches >2 attacks per month, prophylaxis should be considered. Limited
    to 9 tablets per 30 days.
  4. Zolmitriptan 5mg, 10mg ODT/Tablets: Zolmitriptan is step therapy to treatment failure of Imitrex OR Maxalt. For frequent headaches >2 attacks per month, prophylaxis should be considered. Limited to 9 tablets per 30 days.
  5. Eletriptan 20mg, 40mg Tablets: Eletriptan is step therapy to treatment failure to [1] Sumatriptan or Rizatriptan AND [2] Naratriptan or Zolmitriptan in the last 365 days. For frequent headaches >2 per month, prophylaxis with Topamax, Depakote, or beta blockers may be considered. Limited to 9 tablets per 30 days.
  6. Almotriptan 6.25mg, 12.5mg Tablets: Almotriptan is step therapy to treatment failure to [1] Sumatriptan or Rizatriptan AND [2] Naratriptan or Zolmitriptan in the last 365 days. For frequent
    headaches >2 per month, prophylaxis with Topamax, Depakote, or beta blockers may be considered. Limited to 9 tablets per 30 days.
  7. Jardiance (Empagliflozin) 10mg, 25 mg tablets: Step therapy to an adequate trial of Metformin,
    unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related.
    Limited to 30 tablets per 30 days.
  8. Invokana (Canagliflozin) 100mg, 300mg tablets: Step therapy to an adequate trial of
    Metformin AND Empagliflozin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
  9. Farxiga (Dapagliflozin) 5mg, 10mg tablets: Step therapy to an adequate trial of Metformin AND
    Empagliflozin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance
    is GI-related. Limited to 30 tablets per 30 days.
  10. Invokamet (Canagliflozin/Metformin) IR/XR 50mg-500mg, 50mg-1000mg, 150mg-500mg,
    150-1000mg tablets: Step therapy to an adequate trial of Metformin and Empagliflozin, unless
    intolerant/contraindicated. Limited to 60 tablets per 30 days.
  11. Xigduo XR (Dapagliflozin/Metformin): Step therapy to an adequate trial of Metformin and
    Empagliflozin, unless intolerant/contraindicated.

a. 5mg-500mg, 5mg-1000mg tablets: Limited to 60 tablets per 30 days.
b. 10mg-500mg, 10mg-1000mg tablets: Limited to 30 tablets per 30 days.

  1. Victoza (Liraglutide): PA required. Reserved for an inadequate response to an adequate trial of
    Metformin (unless intolerant or contraindicated) for patients with HbA1c < 9%. A trial of
    Metformin ER is required if intolerance is GI-related.
  2. Byetta 5mcg Pen, 10mcg Pen, Bydureon 2mg Vial: PA required. Reserved for an inadequate
    response to an adequate trial of Metformin (unless intolerant or contraindicated) for patients
    with HbA1c < 9% AND who have failed Victoza. A trial of Metformin ER is required if intolerance
    is GI-relate
  3. Montelukast 4 mg granule packet: Restricted to patients under age 2. For patients above age 2,
    reserved for patients with documented inability to use chewable tablets. Limited to 1 packet per
    day.
  4. Flunisolide: PA required. Reserved for treatment failure of an adequate trial (7-14 days) of any 2
    (two) first-line agents (fluticasone, budesonide, and triamcinolone).
  5. Budesonide (Rhinocort Aqua): PA Criteria removed.

Deletions from the Formulary:

The following products will be removed from the formulary as of November 29, 2017:

Drug Formulary Alternatives Grandfather members currently taking
Lantus Vials and Pens Basaglar Kwikpen (Temporarily) Yes
Metformin 500mg ER
(Generic of Fortamet ER)		 Metformin 500mg, 750mg ER (Generic of
Glucophage XR)		 No
Tears Naturale II Eye drops Artificial Tears, Tears Pure Eye Drops No
Antipyrine-Benzocaine, Auredex and
Auroguard		 No Otic Anesthetic available. Use oral pain
reliever.		  No
Captopril 12.5mg, 25mg, 50mg,
100mg tablets		 Enalapril tablets, Lisinopril Tablets, Quinapril
Tablets, Benazepril Tablets		 No
Bumetanide 2mg tablets Furosemide, Torsemide, Ethacrynic Acid,
Bumetanide 0.5mg, 1mg tablets		 No
Clemastine fumarate 1.34 mg tablets Chlorpheniramine tablet, Diphenhydramine
tablet/capsules, Cetirizine HCL tablet,
Loratadine tablet		  No
Clemastine 0.67 mg/5 ml syrup Chlorpheniramine Syrup, Diphenhydramine
Solution, Syrup & ODT, Cetirizine HCL
Solution & ODT, Loratadine Solution & ODT.		 No
Veramyst nasal spray Flonase, Nasacort, Rhinocort Aqua No
Fexofenadine 30 mg tablets Chlorpheniramine, Diphenhydramine,
Fexofenadine 60 & 180mg, Cetirizine HCL,
Loratadine tablets		 No
Cetirizine 5 mg/5ml solution Cetirizine 1 mg/1ml solution No
Beclomethasone 42mcg (Beconase
AQ)		 Flonase, Nasacort, Rhinoquart Aqua Yes

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 888.936.PLAN (7526).

Thank you for your continued support of Health Plan of San Joaquin.

Posted on September 21st, 2017 and last modified on September 22nd, 2017.

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