Formulary updates effective for April 19, 2021

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Date: February 22, 2021
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

Effective 04/19/2021, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

  1. Sodium Ferric Gluconate/Sucrose (Ferrlecit) 62.5mg/5ml vial: No restrictions.
  2. Ferumoxytol (Feraheme) 510mg/17ml vial: Reserved for patients with one or more of the following:
    1. Absolute iron deficiency anemia with a ferritin <30μg/L or TSAT <20% with treatment failure or inability to tolerate oral iron.
    2. Chronic kidney disease with or without dialysis with ferritin < 500μg/L and TSAT <30% with treatment failure or inability to tolerate oral iron for non-dialysis patients.
    3. Chemotherapy-induced anemia with ferritin 30-500μg/L and TSAT <50% in patients receiving ESAs.

Required Information for Approval: Updated ferritin and TSAT levels with documented history of treatment failure or inability to tolerate oral iron. 

Formulary Status Changes:

  1. Iron Sucrose Complex (Venofer) 50mg/2.5ml, 100mg/5ml, 200mg/5ml vials: Reserved for patients with one or more of the following:
  1. Absolute iron deficiency anemia with a ferritin <30μg/L or TSAT <20% with treatment failure or inability to tolerate oral iron.
  2. Chronic kidney disease with or without dialysis with ferritin < 500μg/L and TSAT <30% with treatment failure or inability to tolerate oral iron for non-dialysis patients.
  3. Chemotherapy-induced anemia with ferritin 30-500μg/L and TSAT <50% in patients receiving ESAs.

Required Information for Approval: Updated ferritin and TSAT levels with documented history of treatment failure or inability to tolerate oral iron.

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.

www.hpsj.com/pharmacy-announcements/                            

Posted on February 22nd, 2021

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