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/ Alerts, Pharmacy Announcements / Formulary Update – September 18, 2019

Provider Alerts

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Date: September 18, 2019
To: Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies
From: Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject: Formulary Update – September 18, 2019
Business: Medi-Cal Managed Care

Effective 12/02/2019, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

  1. Heparin sodium porcine/PF 500/5 ML Syringe: Max 7 day supply at a time.
  2. Pilocarpine 5 mg Tablet: Limited to 180 tablets per 30 days.
  3. Vitamin A, C, D-Fluoride 0.5mg/mL drop: No restrictions.
  4. Methotrexate Preservative containing 50mg/2mL vial: No restrictions.
  5. Simethicone 80mg, 125mg Chewable Tablet; Simethicone 125mg, 180mg capsule, Simethicone Liquid: No restrictions.
  6. Trokendi XR capsule; Qudexy XR capsule: PA required. Reserved for treatment of partial onset seizures and primary generalized tonic-clonic seizures or Lennox-Gastaut Syndrome who meet ALL of the following criteria:
    1. Treatment failure/documented intolerance to topiramate immediate release.
    2. Prescribed by a neurologist.
    3. Trokendi XR: Limited to persons ≥ 6 years of age.
    4. Quedexy XR: Limited to persons ≥ 2 years of age.
  7. Briviact tablet: PA required. Limited to persons ≥ 21 years of age. Reserved for treatment of partial onset seizures who meet ALL of the following criteria:
    1. Must be concurrently using at least ONE antiepileptic drug, but not concurrently using Levetiracetam.
    2. Reserved for treatment failure/documented intolerance of Levetiracetam AND ONE of the following: Felbamate, Gabapentin, Lamotrigine, Pregabalin, Oxcarbazepine, Topiramate, Zonisamide.
    3. Must be prescribed by a neurologist.
  8. Aptiom tablet: PA required.Limited to persons ≥ 21 years of age. Reserved for treatment of partial onset seizures who meet ALL of the following criteria:
    1. Must be concurrently using at least ONE antiepileptic drug.
    2. Reserved for treatment failure/documented intolerance to at least TWO of the following medications indicated for adjunct partial seizures: Levetiracetam, Felbamate, Gabapentin, Lamotrigine, Pregabalin, Oxcarbazepine, Topiramate, Zonisamide.
    3. Must be prescribed by a neurologist.
  9. Fycompa tablet: PA required. Limited to persons ≥ 21 years of age. Reserved for treatment of partial onset seizures OR primary generalized tonic-clonic seizures who meet ALL of the following criteria:
    1. Must be concurrently using at least ONE antiepileptic drug.
    2. Must be stable on the medication OR has had an insufficient response or intolerance to at least TWO other antiepileptic drugs.
    3. Must be prescribed by a neurologist.
  10. Xarelto 2.5 mg tablets: PA required.Mandatory bleeding risk assessment and non sex related CHA2DS2‐VASc risk factor ≥ 2. Reserved for treatment of patients with stable CAD or patients with symptomatic PAD with high risk of cardiovascular events. (No recent stroke or previous hemorrhagic or lacunar stroke, severe heart failure, or advanced kidney disease). Requires documentation of inadequate response/intolerance to dual antiplatelet therapy. Expected benefit must outweigh the bleeding and associated risks.Must be prescribed by a cardiologist.
  11. Naldemedine (Symproic) tablet: PA required. Reserved for patients with opioid‐induced constipation with chronic non‐cancer pain and treatment failure of dose‐optimized, regularly scheduled polyethylene glycol for 2 months (as evidenced by prescription history fills) AND two of the following: bisacodyl, Senna, lactulose, magnesium citrate or hydroxide.

Formulary Status Changes:

  1. Isotretinoin 10mg, 20mg, 30mg, 40mg capsule: Limited to 60 tablets per 30 days and fill limit of 6 per 240 days.
  2. Ciprodex Otic Suspension: Step therapy to Ofloxacin Ear or Eye Drops and Dexamethasone 0.1% Eye Drops in the last 365 days.
  3. Nepro: Fill limit of 6 per 365 days, then criteria applies thereafter.
  4. Nicotine Patch: Fill limit of 6 per 365 days.
  5. Varenicline (Chantix) tablet: Fill limit of 6 per 365 days.
  6. Testosterone Cypionate 100mg/mL, 200mg/mL vial: Limited to persons 18 years or older.
  7. Diclofenac 1% (Voltaren) gel: No restrictions.
  8. Cefdinir 300mg capsule: No restrictions.
  9. Entecavir 0.5mg, 1mg tablet: No restrictions.
  10. Itraconazole 100mg capsule: No restrictions.
  11. Sevelamer carbonate 800mg (Renvela) tablet: No restrictions.
  12. Ezetimibe 10mg tablet: No restrictions.
  13. Calcium acetate 667mg capsule: No restrictions.
  14. Topiramate sprinkle: Limited to persons ≤ 12 years of age.
  15. Methylnaltrexone (Relistor)
    1. 150mg Tablet: PA required. Prior treatment requirement with Naldemedine AND Naloxegol due to AGA’s conditional recommendations over no treatment.
    2. Subcutaneous syringe/solution: PA required. Prior treatment requirement with Naldemedine AND Naloxegol due to AGA’s conditional recommendations over no treatment. Reserved for patients with OIC in advanced illness with inability to swallow pills.

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.

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