Provider Alerts

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Date:	March 9, 2017
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 Effective 5/11/2017,
Business:	Medi-Cal, MCAP (Medi-Cal Access Program, previously known as AIM)

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Effective 5/11/2017, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Tofacitinib (Xeljanz XR) for Rheumatoid Arthritis: Reserved for treatment failure to [1] Adalimumab, Etanercept, or Infliximab AND [2] one of the following: Certolizumab, Golimumab, Abatacept, Tocilizumab, OR Rituximab. Must be prescribed by rheumatologist.
2. Secukinumab (Cosentyx) for Psoriatic Arthritis: Reserved for treatment failure/documented intolerance to two 1st line agents (adalimumab, etanercept, infliximab) OR one 1st line agent (adalimumab, etanercept, infliximab) and one 2nd line agent (certolizumab, golimumab). Must be prescribed by rheumatologist or dermatologist.
3. Secukinumab (Cosentyx) for Ankylosing Spondylitis: Reserved for treatment failure/documented intolerance to two 1st line agents (adalimumab, etanercept, infliximab) OR one 1st line agent (adalimumab, etanercept, infliximab) and one 2nd line agent (certolizumab, golimumab). Must be prescribed by rheumatologist.
4. Brinzolamide/Brimonidine (Simbrinza): No PA required.
5. Vigabatrin (Sabril): Restricted to use by Neurologists only. Criteria for use in the following indications:
   1. a. Infantile Spasms:
      1. i. Child must be less than 2 years of age.
      2. ii. Quantity Limit of 150mg/kg/day.
      3. iii. Documentation of visual acuity exam is required prior to initiation.
   2. Complex Partial Seizures:
      1. i. Reserved for patients age 10 and older with documented dose-optimized treatment failure of 3 formulary Anti-Epileptic Agents for complex partial seizures including at least one of the following:
         1. 1. carbamazepine, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, topiramate, valproic acid, divalproex sodium, zonisamide or tiagabine
         2. ii. Sabril must be used in combination with at least one other antiepileptic medication.
         3. iii. Documentation of visual acuity exam is required prior to initiation. iv. For patients age 17 and older: Quantity Limit of 3g per day. v. For patients age 10-16: Quantity Limit of 2g per day.

Formulary Status Changes:

1. Ustekinumab (Stelara) for Psoriasis: Reserved for treatment failure/documented intolerance to adalimumab, etanercept or infliximab. Must be prescribed by dermatologist.
2. Ustekinumab (Stelara) for Psoriatic Arthritis: Reserved for treatment failure/documented intolerance to two 1st line agents (adalimumab, etanercept, infliximab) OR one 1st line agent (adalimumab, etanercept, infliximab) and one 2nd line agent (certolizumab, golimumab). Must be prescribed by rheumatologist or dermatologist.
3. Natalizumab (Tysabri) coverage criteria to include the following required information for approval: Documentation showing contraindication to anti-TNF biologic and a negative anti-JCV antibody detection test result.
4. Micronized Progesterone 100mg, 200mg capsules (Prometrium): Reserved for women with history of preterm birth, short cervix (< 25 mm), or history of 2 miscarriages. Limited to 2 capsules per day. a. Please note therapy may be continued until 37 gestational weeks.
5. Progesterone in oil (50mg/mL): Reserved for women with history of 2 miscarriages.
6. Hydroxyprogesterone caproate (Makena®) 250mg/ml intramuscular oil: Reserved for women with history of singleton pregnancy with history of preterm birth (less than 37 weeks). Therapy must be initiated between 16 weeks, 0 days and 23 weeks, 6 days. Limited to 5 mL per 35 days. a. Please note therapy may be continued until 37 gestational weeks.
7. Pramipexole (Mirapex, Mirapex ER) coverage criteria to include the following: Limited to 90 tablets per 30 days.
8. Ropinirole (Requip, Requip XL) coverage criteria to include the following: Limited to 90 tablets per 30 days.
9. Coverage criteria for ALL formulary biologics (Humira, Cimzia, Enbrel, Simponi, Remicade, Actemra, Cosentyx, Stelara, Orencia, Tysabri, Otezla, Xeljanz, Xeljanz XR) to include the following additional notes section: Biologics exceeding labeled standard maintenance doses may be approved 1 month at a time. Subsequent fills of the increased maintenance dose will require documentation of symptom improvement.
10. Immunizations: Adult immunizations are now available under the pharmacy benefit as well as under the medical benefit. For member’s under the age of 19, routine vaccinations available through the VFC (Vaccines for Children) program will only be available via the VFC program and administered at the provider’s office. Please refer to the HPSJ Immunization Coverage Policy for more details.
11. REMINDER that Memantine (Namenda) requires a PA with the following criteria: Reserved for patients with moderate-to-severe dementia of Alzheimer’s type, based on MMSE score of 3-14

Deletions from the Formulary: The following products will be removed from the formulary as of May 11, 2017:

Drug	Formulary Alternatives	Grandfather members currently taking
Calcitriol 0.5 mcg	Calcitriol 0.25 mcg	No
Crinone 4%, 8% Gel (Progesterone)	Progesterone 100mg, 200mg Capsules	Yes

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 Provider Services Department with any questions or concerns Monday through
Friday 8 a.m. to 5 p.m. at (209) 942-6340 or 1-888-936-PLAN (7526).

Thank you for your continued support of Health Plan of San Joaquin.