Provider Alerts

Effective September 18, 2023, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit.

1. Code Q5121 – INJECTION, INFLIXIMAB-AXXQ, BIOSIMILAR, (AVSOLA), 10 MG: For Psoriasis: PA required. Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, and Acitretin). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Must be prescribed by a dermatologist.

For Ankylosing Spondylitis: PA required. 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. Must be initiated by a rheumatologist. For Rheumatoid Arthritis: 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. Must be initiated by a rheumatologist.

For Psoriatic Arthritis: PA required. Reserved for treatment failure to 12 weeks of dose optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Must be prescribed by a rheumatologist or dermatologist.

2. Code J1747 – INJECTION SPESOLIMAB-SBZO, (SPEVIGO), 1 MG:
For Psoriasis: PA required. Reserved for [1] Treatment of moderate to severe acute flare of generalized pustular psoriasis (defined as a GPPGA total score of ≥3, new or worsening pustules, a GPPGA pustulation subscore of ≥2, and ≥5% of body-surface area with erythema and the presence of pustules) AND [2] The diagnosis of generalized pustular psoriasis must be confirmed by the presence of primary, sterile, macroscopically visible pustules on non-acral skin and pustulation must not be restricted to psoriatic plaques (i.e. occurs outside of psoriatic plaques). Must be prescribed by a dermatologist. Limited to two 900mg doses per month if needed for acute flare.

3. Code J1745 – INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, (REMICADE), 10
MG:
For Psoriatic Arthritis: Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried. Must be prescribed by a rheumatologist or dermatologist.

4. Code J1602 – INJECTION, GOLIMUMAB, (SIMPONI), 1 MG, FOR INTRAVENOUS USE, and J0717 – CERTOLIZUMAB PEGOL, (CIMZIA), 1 MG (CODE MAY BE USED FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED):
For Psoriatic Arthritis: Re-tier as 2nd line biologics with the following criteria: PA required. Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Avsola, or infliximab (Remicade). Must be prescribed by a rheumatologist or dermatologist.

5. Code J0129 – INJECTION, ABATACEPT, (ORENCIA), 10 MG (CODE MAY BE USED
FOR MEDICARE WHEN DRUG ADMINISTERED UNDER THE DIRECT SUPERVISION OF A PHYSICIAN, NOT FOR USE WHEN DRUG IS SELF ADMINISTERED):
For Psoriatic Arthritis: Re-tier as a 2nd line biologic with the following criteria: PA required. Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Avsola, or Remicade. Abatacept may be used instead of a TNF-inhibitor in patients with recurrent or serious infections. Must be prescribed by a rheumatologist or dermatologist.

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If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/