Provider Alerts

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To:	Health Plan of San Joaquin Pharmacy and Therapeutics Committee
From:	Provider Services Department – Health Plan of San Joaquin
Subject:	Provider Alert Formulary Update
Products:	Medi-Cal, AIM

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Effective 9/23/2015, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Fluticasone Furoate (Arnuity Ellipta) – No PA required. Reserved for patients 12 years+. Limited to one inhaler per month.
2. Tiotropium/Olodaterol (Stiolto Respimat) – PA required. Reserved for patient with at least Stage II (moderate) COPD confirmed by pulmonary function testing (PFTs). Limited to one inhaler per month.
3. Ivabradine (Corlanor) – PA required. Restricted to members with:
   • LVEF <35% confirmed by echocardiogram.
   • Resting heart rate greater than 70 BPM.
   • Normal sinus rhythm (atrial fibrillation is a specific exclusion).
   • Compliant use of dose-optimized Beta-blocker, ACE inhibitor/ARB, and Aldosterone Antagonist or have a contraindication to the above drugs.
   • For members unable to tolerate a Beta-blocker, patients must have documented intolerance to three or more beta-blockers, with dose de-escalation, before Ivabradine will be approved as monotherapy.
4. Sacubitril/Valsartan (Entresto) – PA required. Reserved for patients with CHF who have an EF less than 35% confirmed by echocardiogram, are maximized on beta-blocker therapy, and have tried dose-optimized therapy with at least 1 ACE inhibitor and at least 1 ARB.
5. Lantus Solostar, Humalog Kwikpen, Novolog Flexpen, Humulin N Kwikpen, Humalog Mix 75-25 Kwikpen, Novolog Mix 70-30 Flexpen, Humulin 70-30 Kwikpen – No PA required. Limited to 1 box per 60 days. For patients requiring >1 box per 60 days, submit prior authorization.
6. Insulin glargine (Toujeo Solostar) – PA required. Reserved for patients requiring more than 80 units of insulin glargine per injection.
7. Rifabutin (Mycobutin) – PA required.
   • For tuberculosis, reserved for patients on medication regimens that prohibit use of rifampin due to interactions that cannot be avoided by dose adjustment.
   • For Mycobacterium avium complex (MAC) prophylaxis, reserved for HIV+ patients with CD4 count <50 cells/µL who cannot use Azithromycin or Clarithromycin due to intolerance or interactions that cannot be avoided by dose adjustment. Therapy will be discontinued when CD4 count is >100 cells/µL for more than 3 months.
8. Rifapentine (Priftin) – No PA required. Limited to 32 tablets per 30 days.
9. Bedaquiline (Sirturo) – PA required. Approval is determined by medical necessity criteria. Restricted to Diplomat Pharmacy.
10. Aluminum Chloride (Drysol) – No PA required. Limited to one unit per month.
11. Erythropoietin alfa (Epogen) – PA required. Restricted to patients with Hgb <9 g/dL without iron deficiency. Restricted to Diplomat Specialty Pharmacy.
12. Lansoprazole ODT (Prevacid SoluTab) – PA required. Reserved for treatment failure to ranitidine syrup for children <10 years old, OR documented inability to swallow tablets/capsules.

Formulary Status Changes:

1. Tiotropium (Spiriva Respimat): Updated formulary criteria for asthma: Step therapy to Montelukast 10 mg AND one of the following: Symbicort (160mcg/4.5mcg), Advair (500 mcg/50 mcg), or Dulera (200 mcg/5mcg) within the last 30 days. Limited to 1 inhaler per month.
2. Pyrimethamine (Daraprim) – PA required. Restricted to patients unable to take sulfamethoxazole.
3. Ethacrynic Acid (Edecrin) – PA required. Restricted to patients with documented sulfa-allergy or treatment failure of furosemide, torsemide, and bumetanide.

Deletions from the Formulary:

The following products were removed from the formulary as of September 23, 2015:

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 8:00 am to 5:00 pm at (209) 942-6340 or 1-888-936-PLAN (7526).

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