Provider Alerts

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To:	Health Plan of San Joaquin (HPSJ) Physicians and Providers
From:	Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject:	Provider Alert Formulary Update – 5/20/2016
Business:	Medi-Cal, AIM (now known as Medi-Cal Access Program)

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Effective 5/20/2016, the Pharmacy and Therapeutics Committee has approved the following changes:
Additions to the Formulary:

1. Oral Contraceptives (no PA required, restricted to females): Delyla, Levonorgestrel/Ethinyl Estradiol (Portia Generic), Larin 1.5/30, Blisovi 1.5/30, Larin 1/20, Norethindrone 1mg/Ethinyl Estradiol 20mcg (Microgestin 1/20 Generic), Blisovi Fe 1/20, Tarina Fe, Norethindrone 1mg/Ethinyl Estradiol 20mcg/Iron 75mg (Microgestin Fe 1/20 Generic), Cyred, Juleber, Tri-Lo-Marzia, Tri-Lo-Estarylla, Tri-Lo-Sprintec, Norgestimate/Ethinyl Estradiol Triphasic (Ortho Tri-Cyclen Lo Generic), Levonorgestrel/Ethinyl Estradiol Triphasic (Triphasil Generic), Deblitane, Sharobel, Lyza, and Norlyroc
2. Emergency Contraceptives (no restrictions): Econtra EZ, Fallback SOLO, and Opicon One-Step

Formulary Status Changes:

Criteria for 1st line biologics for Rheumatoid Arthritis (RA), Psoriasis (PsO), Psoriatic Arthritis (PsA), Ankylosing Spondylitis (AS), Crohn’s Disease (CD), and Ulcerative Colitis (UC):

	RA	PsO/PsA	AS	CD/UC
1st line	Humira, Enbrel, Remicade	Humira, Enbrel, Remicade	Humira, Enbrel, Remicade	Remicade, Humira
Criteria	Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Leflunomide, Hydroxychloroquine, Sulfasalazine, Azathioprine)* Must be initiated by a rheumatologist.	Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Acitretin, Leflunomide)* Must be initiated by a dermatologist or rheumatologist.	Documented symptomatic AS despite treatment with NSAIDs (unless NSAID-intolerant). An adequate trial is defined as at least 2 different NSAIDs over 1 month or 2 different NSAIDs over 2 months. Must be initiated by a rheumatologist.	Reserved for treatment failure to adequate trial of oral immunosuppressive agents (Azathiopurine, Mercaptopurine, Mesalamine, and Sulfasalazine)* OR intolerance to corticosteroids. Must be initiated by a gastroenterologist.

1. Humira (Adalimumab), Enbrel (Etanercept), Remicade (Infliximab)—PA required. Reserved for treatment failure to adequate trial of DMARD therapy. Restricted to specialty pharmacy.
2. Cimzia (Certolizumab)—PA required. Second-line treatment for RA, PsA, AS, and CD: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent. Restricted to specialty pharmacy.
3. Simponi (Golimumab)—PA required. Second-line treatment for RA, PsA, AS, and UC: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent. Restricted to specialty pharmacy.
4. Orencia (Abatacept)—PA required. Second-line treatment for RA: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent. Restricted to specialty pharmacy.
5. Actemra (Tocilizumab)—PA required. Second-line treatment for RA: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent. Restricted to specialty pharmacy.
6. Rituximab (Rituxan)—PA required. Second-line treatment for RA: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent. Restricted to specialty pharmacy.
7. Xeljanz (Tofacitinib)—PA required. Third-line treatment for RA: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent AND 1 second-line agent. Restricted to specialty pharmacy.
8. Cosentyx (Secukinumab)—PA required. Second-line treatment for PsO and PsA: Reserved for patients who qualify for biologic with treatment failure to at least 1 first-line agent. Restricted to specialty pharmacy.
9. Tysabri (Natalizumab)—PA required. Treatment for CD: Reserved for pts with contraindication to TNF biologic.
10. Otezla (Apremilast)—PA required. Reserved for patients with PsO or PsA who have tried an adequate trial of oral DMARD but cannot use biologics (e.g. history of severe infection, etc). Restricted to specialty pharmacy.
11. Modafinil 200 mg tablets—Modafinil is reserved for treatment of narcolepsy or obstructive sleep apnea treated by a sleep specialist or pulmonologist. For apnea, modafinil is reserved for inadequate response to compliant use of properly-fitting CPAP for at least 90 days.
12. Sodium oxybate —Sodium oxybate is reserved for use in narcolepsy with cataplexy treated by a sleep specialist or pulmonologist.
13. Erthryomycin Ethyl Succinate 400 mg Tablet—1st fill: No Restrictions, Subsequent fills: PA required.
14. Erythromycin Base 250 mg, 500 mg Tablet—1st fill: No Restrictions, Subsequent fills: PA required.
15. Erythromycin Stearate 250 mg Tablet—1st fill: No Restrictions, Subsequent fills: PA required.

Deletions from the Formulary:
The following products were removed from the formulary as of February 16, 2016:

Drug	Formulary Alternatives	Grandfather members currently taking
Kineret (Anakinra)	See above formulary status changes for biologics	N/A
Levonorgestrel 0.75 mg	Levonorgestrel 1.5 mg	No
Trianex (Triamcinolone 0.05% Topical Ointment)	Desonide 0.05%, Fluocinolone 0.025%, Betamethasone Valerate 0.05%	No
Nitroglycerin Lingual 400mcg/spray Solution	Nitroglycerin Sublingual Tablets	No
Dantrolene 25mg, 50mg, 100mg	Baclofen, Cyclobenzaprine, Tizanidine	No

The County of San Joaquin is dedicated to providing all participants the best health care available in the most effective and efficient manner. We believe that this change in their 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 8:00 am to 5:00 pm at (209) 942-6340 or 1-888-936-PLAN (7526).