Post date: February 19, 2019

HPSJ MCL Provider Alert-Formulary Update December 2018

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Date: December 17, 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
Business: Medi-Cal

Effective 2/25/2019, the Pharmacy and Therapeutics Committee has approved the following changes:
 
Additions to the Formulary:

  1. Baloxavir (Xofluza) 20 mg, 40mg tablets: PA required.  Reserved for patients who meet all of the following criteria:
    • 12 years of age or older; 
    • Treatment of acute, uncomplicated influenza (defined as patient’s with influenza who can be treated outpatient and do not require hospitalization); 
    • Documented intolerance to both Oseltamivir and Zanamivir; 
    • Is not currently pregnant; AND 
    • Limited to FDA approved dosing based on weight with a quantity limit of two tablets per strength. 
  2. Erenumab-aooe (Aimovig):  PA required. Reserved for treatment failure to Botox therapy for 12 months.
  3. Levomilnacipran (Fetzima Starter Pack):  PA required. Reserved for treatment failure or documented intolerance to optimally dosed Venlafaxine IR/XR and Duloxetine for two months each.  Limited to 1 titration pack per 180 days.
  4. Milnacipran (Savella Starter pack):  PA required. Reserved for treatment failure or documented intolerance to optimally dosed Venlafaxine IR/XR and Duloxetine for two months each.  Limited to 1 titration pack per 180 days.
  5. Trospium Immediate Release (Sanctura):  Step therapy to treatment failure of or intolerance to Oxybutynin IR/ER in the past 365 days.  
  6. Calcitriol (Rocaltrol) Solution:  PA required.   Reserved for use in chronic kidney disease with documented inability to swallow calcitriol capsules.
  7. Cyanocobalamin (Vitamin B12) Vial: Limited to 1 vial per 28 days.
  8. Vancomycin 125mg Capsules: PA required. PA required: Reserved for recurrent C. difficile infections in a pulse tapered regimen.

Formulary Status Changes:

  1. OnabotulinumtoxinA (Botox):  PA required.  Reserved for patients who meet all of the following criteria:
    1. Must be prescribed by a Neurologist  
    2. Age 18 years or older  
    3. ≥ 15 or more days per month for ≥ 3 months  
    4. ≥ 4 hours a day or longer duration, as indicated by 5 or more attacks with ALL of the following:  
      1. Headache symptoms, as indicated by 2 or more of the following:
        1. Aggravation by or causing avoidance of routine physical activity 
        2. Moderate or severe pain intensity 
        3. Pulsating quality 
        4. Unilateral location 
      2. Migraine-associated symptoms, as indicated by 1 or more of the following:  1. Nausea or vomiting 
      3. Photophobia and phonophobia 
      4. Other potential causes of headaches have been excluded. 
      5. Use 3 different preventive medications at therapeutic dose (eg, beta-blocker, calcium channel blocker, tricyclic antidepressant, anticonvulsant) unless therapy has been ineffective or not tolerated for trial of at least 3 months each. 
      6. No neuromuscular disease (eg, myasthenia gravis)
  2. Female Condoms (FC2 Female Condoms):  Limited to 6 condoms per 30 days.
  3. Duloxetine (Cymbalta):  No PA required.
    1. Duloxetine 20mg, 30mg capsules: Limited to 60 capsules per 30 days.
    2. Duloxetine 60 mg capsules: Limited to 30 capsules per 30 days.
  4. Milnacipran (Savella):  PA required. Reserved for treatment failure or documented intolerance to optimally dosed Venlafaxine IR/XR and Duloxetine for two months each.
  5. Citalopram 10mg/5ml Solution (Celexa):  PA required.  Reserved for documented inability to consume capsules or tablets by mouth.
  6. Escitalopam 5mg/5ml Solution (Lexapro):  PA required.  Reserved for documented inability to consume capsules or tablets by mouth.
  7. Fluoxetine 20mg/5ml Solution (Prozac):  PA required.  Reserved for documented inability to consume capsules or tablets by mouth.
  8. Nortriptyline 10mg/5ml Solution:  PA required.  Reserved for documented inability to consume capsules or tablets by mouth.
  9. Paroxetine 10mg/5ml Solution (Paxil):  PA required.  Reserved for documented inability to consume capsules or tablets by mouth.
  10. Sertraline 20mg/ml Solution (Zoloft):  PA required.  Reserved for documented inability to consume capsules or tablets by mouth.
  11. Trospium XR (Sanctura XR):   PA required.   Reserved for treatment failure or intolerance to Oxybutynin IR (unless over 65), Oxybutynin ER and Trospium IR (unless over 65) in the past 365 days.
  12. Tolterodine ER (Detrol LA):   PA required.  Reserved for treatment failure or intolerance to Oxybutynin IR (unless over 65), Oxybutynin ER, and Trospium IR (unless over 65) or XR in the past 365 days.
  13. Darifenacin (Enablex):   PA required.  Reserved for treatment failure or intolerance to Oxybutynin IR (unless over 65), Oxybutynin ER, and Trospium IR (unless over 65) or XR in the past 365 days.
  14. Solifenacin (Vesicare):  PA required.  Reserved for treatment failure or intolerance to Oxybutynin IR (unless over 65), Oxybutynin ER, Trospium IR (unless over 65) or XR, Detrol LA and Enablex.
  15. Fesoterodine (Toviaz):  PA required.  Reserved for treatment failure or intolerance to Oxybutynin IR (unless over 65), Oxybutynin ER, Trospium IR (unless over 65) or XR, Detrol LA and Enablex.
  16. Ertugliflozin/Metformin (Segluromet): Limited to 60 tablets per 30 days for all strengths.
  17. Pioglitazone/Metformin (Actoplus Met):   
    1. Immediate Release 15mg-500mg Tablets, 15mg-850mg tablets: Limited to 90 tablets per 30 days.
    2. Extended Release 15mg-1000mg Tablets: Limited to 60 tablets per 30 days.
    3. Extended Release 30mg-1000mg Tablets: Limited to 30 tablets per 30 days.

Deletions from the Formulary:
The following products will be removed from the formulary as of February 25, 2019:

Drug

Formulary Alternatives

Grandfather members currently taking 

Maxidex 0.1% ophthalmic suspension

Prednisolone, Fluorometholone ophthalmic suspension

No

Vexol 1% ophthalmic suspension

Prednisolone, Fluorometholone ophthalmic suspension

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.

You may contact our Customer Service Department with any questions or concerns Monday through Friday 8 a.m. to 6 p.m. at (209) 942-6320 or 1-888-936-PLAN (7526).  Thank you for your continued support of Health Plan of San Joaquin.

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