Provider Alerts - September 27, 2018

Provider Alert – Formulary update effective 12/10/2018

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Date: September 27, 2018
To: Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies
From: Health Plan of San Joaquin Pharmacy and Therapeutics Committee
Subject: Provider Alert – Formulary update effective 12/10/2018
Business: Medi-Cal

Effective 12/10/2018, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

  1. Abaloparatide (Tymlos) 3120mcg/1.56mL pen-injector: PA required. Reserved for treatment of osteoporosis as evidenced by documented t-score <-2.5 in patients with treatment failure to 1 year of Prolia with calcium supplementation.
    1. Limited to 1 pen (1.56mL) per 28 days.
    2. Restricted to Specialty Pharmacy.
    3. Limited to 24 total months of treatment.
  2. Antineoplastic Agents: PA required.  Approval is determined by medical necessity criteria. May be restricted to Specialty Pharmacy.

    Generic Name

    Brand Name

    Strength

    Atezolizumab

    Tecentriq

    1200 Mg/20

    Avelumab

    Bavencio

    200Mg/10Ml

    Bevacizumab

    Avastin

    25 Mg/Ml

    Bexarotene

    Targretin

    75 Mg

    Bleomycin Sulfate

    Blenoxane

    15 Unit

    Bleomycin Sulfate

    Blenoxane

    30 Unit

    Cetuximab

    Erbitux

    100Mg/50Ml

    Cobimetinib Fumarate

    Cotellic

    20 Mg

    Dactinomycin

    Cosmegen

    0.5 Mg

    Daunorubicin Hcl

    Cerubidine

    5 Mg/Ml

    Doxorubicin Hcl

    Adriamycin

    10 Mg

    Doxorubicin Hcl

    Adriamycin

    50 Mg

    Doxorubicin Hcl

    Adriamycin

    2 Mg/Ml

    Doxorubicin Hcl Peg-Liposomal

    Doxil/Lipodox

    2 Mg/Ml

    Durvalumab

    Imfinzi

    120 Mg/2.4

    Durvalumab

    Imfinzi

    500Mg/10Ml

    Epirubicin Hcl

    Epirubicin Hcl

    50 Mg

    Epirubicin Hcl

    Epirubicin Hcl

    200 Mg

    Epirubicin Hcl

    Ellence

    50 Mg/25Ml

    Idarubicin Hcl

    Idamycin Pfs

    1 Mg/Ml

    Irinotecan Hcl

    Camptosar

    40 Mg/2 Ml

    Irinotecan Hcl

    Camptosar

    300Mg/15Ml

    Irinotecan Liposomal

    Onivyde

    43 Mg/10Ml

    Ixabepilone

    Ixempra

    15 Mg

    Ixabepilone

    Ixempra

    45 Mg

    Mitomycin

    Mutamycin

    5 Mg

    Mitomycin

    Mutamycin

    20 Mg

    Mitomycin

    Mutamycin

    40 Mg

    Mitomycin

    Mitomycin-Sterile Water

    20 Mg/40Ml

    Necitumumab

    Portrazza

    800Mg/50Ml

    Panitumumab

    Vectibix

    100 Mg/5Ml

    Pertuzumab

    Perjeta

    420Mg/14Ml

    Streptozocin

    Zanosar

    1 G

    Topotecan Hcl

    Hycamtin

    0.25 Mg

    Topotecan Hcl

    Hycamtin

    1 Mg

    Topotecan Hcl

    Hycamtin

    4 Mg

    Topotecan Hcl

    Topotecan Hcl

    4 Mg/4 Ml

    Trametinib Dimethyl Sulfoxide

    Mekinist

    0.5 Mg

    Trametinib Dimethyl Sulfoxide

    Mekinist

    2 Mg

    Trastuzumab

    Herceptin

    150 Mg

    Trastuzumab

    Herceptin

    440 Mg

    Valrubicin

    Valstar

    40 Mg/Ml

    Vinblastine Sulfate

    Vinblastine Sulfate

    1 Mg/Ml

    Vincristine Sulfate

    Vincasar Pfs

    1 Mg/Ml

    Vincristine Sulfate Liposomal

    Marqibo

    Fnl 5Mg/31

    Vinorelbine Tartrate

    Navelbine

    10 Mg/Ml

  3.  Insulin Lispro (Admelog) 100 units/mL vial: No restrictions.
  4.  Insulin Lispro (Admelog Solostar) 100 units/mL pen: Limited to 1 box (15mL) per 30 days.
  5. Ertugliflozin (Steglatro) 5mg, 15mg tablets: Step therapy to an adequate trial of Metformin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
  6.  Ertugliflozin/Metformin (Segluromet) 2.5-500mg, 2.5-1000mg, 7.5-500mg, 7.5-1000mg tablets: No restrictions.
  7.  Irbesartan/Hydrochlorothiazide (Avapro HCT) 150-12.5mg, 300-12.5mg tablets: Step therapy to treatment failure of Losartan 00mg/day in the past 90 days.
  8. Olmesartan (Benicar): Step therapy to treatment failure of Losartan 100mg/day in the past 90 days.
    a. 5mg tablet: Limited to 60 tablets per 30 days.
    b. 20mg, 40mg tablet: Limited to 30 tablets per 30 days.
  9. Olmesartan/Hydrochlorothiazide (Benicar HCT) 20-12.5mg, 40-12.5mg, 40-25mg tablets: Step therapy to treatment failure of Losartan 100mg/day in the past 90 days. Limited to 30 tablets per 30 days.
  10. Tadalafil (Adcirca) 20 mg tablets: PA required. Reserved for treatment failure or intolerance to dose optimized sildenafil for at least 3 months.
  11. Hepatitis B Vaccine (Recombinant, Adjuvanted) (Heplisav-B): No restrictions.
  12. Vancomycin (Firvanq) 25mg/mL (300mL bottle only), 50mg/mL solution (150mL and 300mL bottle): PA required. Reserved for Clostridium difficile infections as evidenced by C. difficile toxin assay or C. difficile DNA PCR.
  13. Vitamin D3 (Cholecalciferol) 2000 unit, 5000 unit tablets: No restrictions.

Formulary Status Changes:

  1. Teriparatide (Forteo) 600mcg/2.4mL solution: PA required. Reserved for treatment of osteoporosis as evidenced by documented t-score <-2.5 in patients OR with treatment failure to year of Prolia with calcium supplementation AND treatment failure or intolerance to Abaloparatide.
    1. Limited to 1 pen (2.4mL) per 28 days.
    2. Restricted to Specialty Pharmacy.
    3. Limited to 24 total months of treatment.
  1. Risedronate (Actonel): PA required. Reserved for treatment failure or intolerance to [1] Alendronate (Fosamax), and [2] Ibandronate (Boniva) unless patient has documented high risk factors for hip or non-vertebral fractures. Current quantity limits on all formulary strengths will still apply.
  2. Insulin Glargine (Basaglar Kwikpen) 100 units/mL pen: Limited to 1 box (15mL) per 30 days.
  3. Invokana (Canagliflozin) 100mg, 300mg tablets: Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
  4. Farxiga (Dapagliflozin) 5mg, 10mg tablets: Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated. A trial of Metformin ER is required if intolerance is GI-related. Limited to 30 tablets per 30 days.
  5. Invokamet (Canagliflozin/Metformin) IR/XR 50mg-500mg, 50mg-1000mg, 150mg-500mg, 150-1000mg tablets: Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated. Limited to 60 tablets per 30 days.
  6. Xigduo XR (Dapagliflozin/Metformin): Step therapy to an adequate trial of [1] Metformin AND [2] Empagliflozin or Ertugliflozin, unless intolerant/contraindicated.
    1. 5mg-500mg, 5mg-1000mg tablets: Limited to 60 tablets per 30 days.
    2. 10mg-500mg, 10mg-1000mg tablets: Limited to 30 tablets per 30 days.
  7. Irbesartan (Avapro) 75mg, 150mg, 300mg tablets: Step therapy to treatment failure of Losartan 100mg/day in the past 90 days.
  8. Clonidine (Catapres-TTS) 0.1mg/24hr, 0.2mg/24hr, 0.3mg/24hr patches: PA required. Reserved for documented inability to take medications by mouth. Limited to 4 patches per 28 days.
  9. Orlistat (Xenical, Alli), Phentermine 37.5 mg tablets: PA required. Reserved for individuals who have received exercise and dietary counseling at least twice by a registered dietitian AND one of the following: [1] BMI of ≥ 27 with 2 or more comorbidities OR [2] BMI > 30.
  10. Hepatitis C Coverage Criteria per DHCS (effective 07/01/2018): Treatment is recommended for all patients with chronic HCV infection, except those with a short life expectancy who cannot be remediated by HCV therapy, liver transplantation, or another directed therapy.

Deletions from the Formulary:
The following products will be removed from the formulary as of December 10, 2018:

Drug

Formulary Alternatives

Grandfather members
currently taking 

Humalog 100 units/mL 
Vial and Kwikpen

Admelog 100 units/mL Vials and Solostar

Yes

Cardizem LA 120mg,
180mg, 240mg, 300mg,
360mg, 420mg tablets

Cardizem CD capsules:  120mg, 180mg, 240mg, 300mg
Cartia XT capsules: 120mg, 180mg, 240mg, 300mg Dilacor XR capsules: 120mg, 180mg, 240mg
Taztia XT capsules: 120mg, 180mg, 240mg, 300mg
Tiazac capsules: 120mg, 180mg, 240mg, 300mg, 420mg

Yes

Matzim LA 180mg,
240mg, 300mg, 360mg, 420mg tablets

Cardizem CD capsules:  120mg, 180mg, 240mg, 300mg
Cartia XT capsules: 120mg, 180mg, 240mg, 300mg Dilacor XR capsules: 120mg, 180mg, 240mg
Taztia XT capsules: 120mg, 180mg, 240mg, 300mg
Tiazac capsules: 120mg, 180mg, 240mg, 300mg, 420mg

Yes

Vancomycin 125mg capsules

Vancomycin (Firvanq) 25 mg/mL (300mL bottle), 50 mg/mL solution (150mL, 300mL bottle)

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 5 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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