The following changes to SFHP formulary and prior authorization criteria were reviewed and approved by the SFHP P&T Committee on 07/15/2015 Effective date for all changes: 08/15/2015
Therapeutic Classes reviewed:
Agents for Insomnia Angiotensin II receptor blockers (ARBs) Anticoagulants Platelet Aggregation Inhibitors Interim Formulary Changes
Prior Authorization Criteria Updates
Agents for Insomnia (updated) Angiotensin II receptor blockers (ARBs) (updated) Anticoagulants (updated) Platelet Aggregation Inhibitors (updated) Multiple Sclerosis (updated) Nicotine Replacement Therapy (new) Hepatitis B (updated) Oral Antivirals (updated) Lyrica (updated)
Policies/Forms Approved
Emergency Medication Supply Policy and Procedure (updated) o Anticoagulant medications (dabigatran (Pradaxa); edoxaban (Savaysa)) have been added in the Emergency Medication Supply Policy and Procedure drug list. o Treatment of Hepatitis B Tenofovir (Viread) and Lamivudine (Epivir‐HBV) for treatment of Hepatitis B have been removed from the Emergency Medication Supply Policy and Procedure drug list. These medications are Fee‐for‐Service (FFS) Medi‐Cal carve‐outs and should
be billed to FFS Medi‐Cal.
Approved Formulary Changes: Agents for Insomnia Medication (GCN)
Formulary Status & DUR ‐ MediCal Zolpidem (Edluar®) sublingual tablet Non‐formulary (GCN 26182 26183) Zolpidem (Intermezzo®) sublingual Non‐formulary tablet (GCN 31563 31562) Zolpidem (Zolpimist®) spray pump Non‐formulary (GCN 29375) Eszopiclone (Lunesta)* tablet (GCN Formulary #1/day, ≥21 y/o 23925 23926 23927) Zaleplon (Sonata®)* tablet (GCN Formulary #1/day, ≥21 y/o 92713 92723)
Formulary Status & DUR – HK Non‐formulary
Formulary Status & DUR – Formulary Status HSF & DUR – CWRAP Non‐formulary No changes
Non‐formulary
Non‐formulary
No changes
Non‐formulary
Non‐formulary
No changes
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o No changes
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o No changes
Angiotensin II receptor blockers (ARBs) Medication (GCN) ARBs Candesartan (Atacand)* GCN 73542, 73543, 73544, 73545 Eprosartan* (Teveten) GCN 93456 Irbesartan (Avapro)* GCN 04752, 04749, 04750 Telmisartan (Micardis)* GCN 23833, 23831, 23832 Valsartan (Diovan)* GCN 18092, 13846, 13844, 13838
Formulary Status & DUR ‐ MediCal ST (losartan, irbesartan, valsartan; 24 mo look‐back period) Non‐formulary Formulary #1/day, ≥21 y/o
Formulary Status & DUR – HK ST (losartan, irbesartan, valsartan; 24 mo look‐back period) Non‐formulary Formulary #1/day, ≥21 y/o
Formulary Status & DUR – HSF ST (losartan, irbesartan, valsartan; 24 mo look‐ back period) Non‐formulary Formulary #1/day, ≥21 y/o
Formulary Status & DUR – CWRAP No changes
Non‐formulary
Non‐formulary
Non‐formulary
No changes
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o No changes
No changes No changes
Medication (GCN) ARBs combos Candesartan/Hydrochlorothiazide (Atacand HCT)* GCN 21559, 13258
Irbesartan/Hydrochlorothiazide* (Avalide) GCN 11042, 11295 Telmisartan/Hydrochlorothiazide (Micardis HCT)* GCN 22866, 12257, 12259 Telmisartan/Amlodipine (Twynsta)* GCN 27783, 27784, 27785, 27786 Valsartan/Hydrochlorothiazide (Diovan HCT)* GCN 07833, 09760, 17245, 27015, 27014 Valsartan/Amlodipine (Exforge)* GCN 97962, 97963, 98579, 98580
Formulary Status & DUR ‐ MediCal ST (losartan HCTZ, irbesartan HCTZ, valsartan HCTZ; 24 mo look‐back period) Formulary #1/day, ≥21 y/o
Formulary Status & DUR – HK ST (losartan HCTZ, irbesartan HCTZ, valsartan HCTZ; 24 mo look‐back period) Formulary #1/day, ≥21 y/o
Formulary Status & DUR – HSF ST (losartan HCTZ, irbesartan HCTZ, valsartan HCTZ; 24 mo look‐back period) Formulary #1/day, ≥21 y/o
Formulary Status & DUR – CWRAP No changes
Non‐formulary
Non‐formulary
Non‐formulary
No changes
Non‐formulary
Non‐formulary
Non‐formulary
No changes
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o No changes
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o
Formulary #1/day, ≥21 y/o No changes
No changes
Anticoagulants Drug Name/Strength/Dosage Form
Formulary Status and DUR Formulary Status and DUR ‐ ‐ Medi‐Cal Healthy Kids
Fondaparinux (Arixtra) syringe 2.5 mg/0.5 ml ** Non‐formulary 5 mg/0.4 ml ** Non‐formulary 7.5 mg/0.6 ml ** Non‐formulary
Non‐formulary Non‐formulary Non‐formulary
Formulary Status and DUR ‐ Healthy SF Non‐formulary Non‐formulary Non‐formulary
Formulary Status and DUR ‐CWRAP
No changes No changes No changes
Formulary Status and DUR Formulary Status and DUR ‐ ‐ Medi‐Cal Healthy Kids
Drug Name/Strength/Dosage Form 10 mg/0.8 ml ** Non‐formulary Rivaroxaban (Xarelto) tablet 15 mg Formulary, AL min 21y, QL #30/30 days 20 mg Formulary, AL min 21y, QL #30/30 days 10 mg Formulary, AL min 21y, QL #30/30 days 15‐20 mg dose pack Formulary, AL min 21y, QL #51/30 days Apixaban (Eliquis) tablet 2.5 mg Formulary, AL min 21y, QL #60/30 days 5 mg Formulary, AL min 21y, QL #60/30 days Edoxaban (Savaysa) tablet 15 mg PA required 30 mg PA required 60 mg PA required
Non‐formulary Formulary, AL min 21y, QL #30/30 days Formulary, AL min 21y, QL #30/30 days Formulary, AL min 21y, QL #30/30 days Formulary, AL min 21y, QL #51/30 days Formulary, AL min 21y, QL #60/30 days Formulary, AL min 21y, QL #60/30 days PA required PA required PA required
Formulary Status and DUR ‐ Healthy SF Non‐formulary Formulary, AL min 21y, QL #30/30 days Formulary, AL min 21y, QL #30/30 days Formulary, AL min 21y, QL #30/30 days Formulary, AL min 21y, QL #51/30 days Formulary, AL min 21y, QL #60/30 days Formulary, AL min 21y, QL #60/30 days No changes No changes No changes
Formulary Status and DUR ‐CWRAP No changes No changes No changes No changes No changes No changes No changes No changes No changes No changes
Platelet Aggregation Inhibitors Drug Name/Strength/Dosage Form Prasugrel (Effient) tablet 5 mg
10 mg
Formulary Status and DUR Formulary Status and DUR Formulary Status and DUR ‐ ‐ Medi‐Cal ‐ Healthy Kids Healthy SF Formulary, ST, QL#1/day, Formulary, ST, QL#1/day, Formulary, ST, QL#1/day, AL AL min 21 y with AL min 21 y with min 21 y with grandfathering grandfathering grandfathering Formulary, ST, QL#1/day, Formulary, ST, QL#1/day, Formulary, ST, QL#1/day, AL AL min 21 y AL min 21 y min 21 y
Formulary Status and DUR ‐ CWRAP No changes
No changes
Clopidogrel (Plavix) tablet 75 mg** Cilostazol (Pletal) tablet 50 mg**
100 mg**
Ticlopidine HCl (Ticlid) tablet 250 mg**
Formulary, AL min 21 y Formulary, AL min 21 y Formulary, AL min 21 y with with grandfathering with grandfathering grandfathering Formulary, QL#60/30 days, Formulary, QL#60/30 days, Formulary, QL#60/30 days, AL AL min 21y with AL min 21y with min 21y with grandfathering grandfathering grandfathering Formulary, QL#60/30 days, Formulary, QL#60/30 days, Formulary, QL#60/30 days, AL min 21y with grandfathering AL min 21y with AL min 21y with grandfathering grandfathering Non‐formulary Non‐formulary No changes
No changes No changes
No changes
No changes
Other Formulary Changes Drug Name/Strength/Dosage Form/GCN
Acetylcysteine 10% vial (2400) $71.33/270mL (up to 300mL per UptoDate) Sodium chloride 3% vial (2373) $18/240mL Sodium chloride 7% vial (98520) $18/240mL Sodium chloride 0.9% for irrigation (45360) $7.90/4L Mesalamine (Pentasa®) 250mg ER capsule (30220) Mesalamine (Pentasa®) 500mg ER capsule Alendronate (Binosto) 70mg effervescent tablet
Formulary Status and DUR ‐ Medi‐Cal
Formulary Status and DUR ‐ Healthy Kids
Formulary #300mL per 30 days Formulary Formulary Formulary
Formulary #300mL per 30 days Formulary Formulary Formulary
Formulary Status and DUR Formulary ‐ Healthy SF Status and DUR ‐ CWRAP Formulary #300mL per 30 No change days Formulary No change Formulary No change Formulary No change
Formulary, QL#360/30 days Formulary, QL#240/30 days Non‐formulary with self‐
Formulary, QL#360/30 days Formulary, QL#240/30 days Non‐formulary with self‐
Formulary, QL#360/30 days Formulary, QL#240/30 days Non‐formulary with self‐
No change No change No change
Drug Name/Strength/Dosage Form/GCN
Alendronate sodium 5 mg tablet (21682) Alendronate sodium 10mg tablet (21680) Alendronate sodium 35mg tablet (12389) Trandolapril 1, 2, 4 mg tablet (32191, 32192, 32193) Captopril 50 mg‐hydrochlorothiazide 25 mg tablet (54943) erythromycin‐benzoyl peroxide 3 %‐5 % topical gel (85400) Metformin ER 750 mg (19578), metformin ER 1000 mg (21831)
Sodium sulfacetamide ‐ various formulations (12691, 15411, 15556, 23229, 27951, 28226, 28227, 28865, 29180, 30172, 48810, 97666, 98458, 99562) ProAir® HFA 90mcg/ actuation inhaler (22913)
Desmopressin acetate 0.1mg tablet (26171)
Typhoid vaccine (Vivotrif) (48429) Atovaquone‐Proguanil 62.5/25 mg, 250/100 mg (Malarone) (89892, 89891) Auvi‐Q 0.3 Mg Auto‐Injector (19862) Duloxetine^ (23161, 23162, 23164)
Formulary Status and DUR ‐ Medi‐Cal grandfathering Formulary w/o age restriction Formulary w/o age restriction Formulary w/o age restriction Non‐formulary
Formulary Status and DUR ‐ Healthy Kids grandfathering Formulary w/o age restriction Formulary w/o age restriction Formulary w/o age restriction Non‐formulary
Formulary Status and DUR ‐ Healthy SF grandfathering Formulary w/o age restriction Formulary w/o age restriction Formulary w/o age restriction No changes
Formulary Status and DUR
Non‐formulary
Non‐formulary
No changes
No changes
Non‐formulary
Non‐formulary
No changes
No changes
Non‐formulary with POS message “Use metformin ER 500 mg”
Non‐formulary with POS message “Use metformin ER 500 mg”
No changes
Non‐formulary
Non‐formulary
No changes but add POS message with POS message “Use metformin ER 500 mg” No changed
Formulary, ST w/ Ventolin®, QL #17grams/30 days with POS message “Use Ventolin” Formulary w/o age restriction, QL #30/30 days Formulary #4 per fill, 2 fills per year Formulary #90 per fill, 2 fills per year Non‐formulary Formulary #60/30 days
Formulary, ST w/ Ventolin®, QL#17grams/30 days with POS message “Use Ventolin” Formulary w/o age restriction, QL #30/30 days Formulary #4 per fill, 2 fills per year Formulary #90 per fill, 2 fills per year Non‐formulary Formulary #60/30 days
No changes No changes No changes No changes
No changes
Formulary, ST w/ No changes Ventolin®, QL#17grams/30 days with POS message “Use Ventolin” Formulary w/o age No changes restriction, QL #30/30 days Formulary #4 per fill, 2 fills per year Formulary #90 per fill, 2 fills per year Non‐formulary Formulary #60/30 days
No changes No changes No changes No changes
Drug Name/Strength/Dosage Form/GCN Valacylovir^^ (13742, 13740) Nicotine Replacement Therapy Nicotine 2 mg lozenge (14689) Nicotine 4 mg lozenge (14688) Nicotine 2, 4 mg gum (03200, 03201)
Nicotine patch 7, 14, 21 mg/24 hr (03421, 03422, 03423) Multiple Sclerosis Agents Oral Dimethyl fumarate (Tecfidera®) 120, 240 mg capsule (34433, 34434, 34435) Fingolimod (Gilenya®) 0.5 mg capsule (29073) Teriflunomide(Aubagio®) 7, 14 mg tablet (33259, 33262) Injectable Glatiramer acetate (Copaxone®) (17178, 35983) IFN beta‐1a (Avonex®) injection (17486, 20147, 20908) IFN beta‐1a (Rebif®) (15914, 15918, 24286, 34166, 34167) IFN beta‐1b (Betaseron ®) injection (98376) IFN beta‐1b (Extavia®) injection (70023, 98376)
Formulary Status and DUR ‐ Medi‐Cal Formulary #90/30
Formulary Status and DUR ‐ Healthy Kids Formulary #90/30
Formulary Status and DUR Formulary ‐ Healthy SF Status and DUR Formulary #90/30 No changes
Formualry #360/30 days no fill limit Formualry #360/30 days no fill limit No changes OR Formulary #360 per 30 days , no fill limit No changes OR Formulary #30 per 30 days, no fill limit
Formualry #360/30 days no fill limit Formualry #360/30 days no fill limit No changes OR Formulary #360 per 30 days , no fill limit No changes OR Formulary #30 per 30 days, no fill limit
Formualry #360/30 days no fill limit Formualry #360/30 days no fill limit No changes OR Formulary #360 per 30 days , no fill limit No changes OR Formulary #30 per 30 days, no fill limit
No changes
PA required
PA required
No changes
No changes
No changes No changes
No changes No changes
No changes No changes
No changes No changes
No changes No changes
No changes No changes
No changes No changes
No changes No changes
Non‐formulary
Non‐formulary
No changes
No changes
Non‐formulary Non‐formulary
Non‐formulary Non‐formulary
No changes No changes
No changes No changes
No changes No changes
No changes
Interim Formulary Changes Drug Name (GCN)
Medi‐Cal (proposed)
Guaifenesin ER 600 mg tablet (02487) Guaifenesin ER 600 mg tablet (35905) Ribavirin 200 mg tabs (18969) Ribavirin 200 mg caps (14179) Various Tenofovir (Viread) Lamivudine (Epivir‐ HBV) Sacubitril and valsartan (Entresto) Anticoagulants
Non‐formulary
Healthy Kids (proposed) Non‐formulary
Healthy SF (proposed) Non‐formulary
CWRAP (proposed) Non‐ formulary Formulary
Effective Date 4/15/15
Formulary
Excluded (OTC)
Formulary
Formulary #168 per 28 days, 6 fills per lifetime Formulary #168 per 28 days, 6 fills per lifetime Formulary without gender edit Excluded
Formulary #168 per 28 days, 6 fills per lifetime Formulary #168 per 28 days, 6 fills per lifetime Formulary without gender edit No changes
Formulary #168 per 28 days, 6 fills per lifetime Formulary #168 per 28 days, 6 fills per lifetime Formulary without gender edit No changes
No changes
4/15/15
No changes
4/15/15
No changes
5/28/15
No changes
7/30/15
PA required
PA required
Non‐formulary
Excluded
7/30/15
Added to emergency supply policy
Added to emergency supply policy
No changes
No changes
5/26/15
4/15/15
April Interim Formulary Changes BRAND NAME
GENERIC NAME
STRENGT H
DOSAGE FORM
ROUTE
COMMENT S
Medi‐Cal
Healthy Kids
NOVOEIGHT
ANTIHEMOPH.FVII I,B‐DOM TRUNCAT
250 ( +/‐)
VIAL
INTRAVEN .
New Entity
Keep non‐ formulary
NOVOEIGHT
ANTIHEMOPH.FVII I,B‐DOM TRUNCAT
500 ( +/‐)
VIAL
INTRAVEN .
New Entity
Keep non‐ formulary
Keep non‐ formulary
Excluded (covered by Part D)
NOVOEIGHT
ANTIHEMOPH.FVII I,B‐DOM TRUNCAT
1000 ( +/‐)
VIAL
INTRAVEN .
New Entity
Keep non‐ formulary
Keep non‐ formulary
Excluded (covered by Part D)
NOVOEIGHT
ANTIHEMOPH.FVII I,B‐DOM TRUNCAT
1500 ( +/‐)
VIAL
INTRAVEN .
New Entity
Keep non‐ formulary
Keep non‐ formulary
Excluded (covered by Part D)
NOVOEIGHT
ANTIHEMOPH.FVII I,B‐DOM TRUNCAT
2000 ( +/‐)
VIAL
INTRAVEN .
New Entity
Keep non‐ formulary
Keep non‐ formulary
Excluded (covered by Part D)
NOVOEIGHT
ANTIHEMOPH.FVII I,B‐DOM TRUNCAT
3000 ( +/‐)
VIAL
INTRAVEN .
New Entity
Keep non‐ formulary
Keep non‐ formulary
Excluded (covered by Part D)
KALYDECO
IVACAFTOR
50 MG
GRAN PACK
ORAL
New Strength and Dosage Form
Excluded (FFS Medi‐ Cal carve‐ out) Excluded (FFS Medi‐ Cal carve‐ out) Excluded (FFS Medi‐ Cal carve‐ out) Excluded (FFS Medi‐ Cal carve‐ out) Excluded (FFS Medi‐ Cal carve‐ out) Excluded (FFS Medi‐ Cal carve‐ out) PA required
Healthy San Francisco Keep non‐ formulary
PA required
Keep non‐ formulary
Excluded (covered by Part D)
CWrap
Excluded (covered by Part D)
BRAND NAME
GENERIC NAME
KALYDECO
STRENGT H
DOSAGE FORM
ROUTE
COMMENT S
Medi‐Cal
Healthy Kids
IVACAFTOR
75 MG
GRAN PACK
ORAL
PA required
PA required
MYOVIEW
KIT FOR PREP TC‐ 99M/TETROFOS
1.38 MG
VIAL
INTRAVEN .
New Strength and Dosage Form New Strength
ISAVUCONAZONIU 372 MG M SULFATE
VIAL
INTRAVEN .
New Entity
OMIDRIA
PHENYLEPHRINE/ KETOROLAC
1 %‐0.3 %
VIAL
INTRAOC ULR
AVYCAZ
CEFTAZIDIME/AVI BACTAM
2.5 G
VIAL
INTRAVEN .
LILETTA
LEVONORGESTREL 18.6MCG/2 4
IUD
INTRAUTE RI
New Combinatio n New Combinatio n New Strength
JADENU
DEFERASIROX
90 MG
TABLET
ORAL
New Entity
Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded (Medical Benefit) PA required
Keep non‐ formulary
CRESEMBA
Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded (Medical Benefit) PA required
JADENU
DEFERASIROX
180 MG
TABLET
ORAL
New Entity
PA required
PA required
Keep non‐ formulary
JADENU
DEFERASIROX
360 MG
TABLET
ORAL
New Entity
PA required
PA required
Keep non‐ formulary
Healthy San Francisco Keep non‐ formulary
Keep non‐ formulary Keep non‐ formulary Keep non‐ formulary Keep non‐ formulary Keep non‐ formulary
CWrap
Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D) Excluded (covered by Part D)
May Interim Formulary Changes ROUTE
COMMENTS
Medi‐Cal
Healthy Kids
Healthy San Francisco
CWrap
SYRINGE
INJECTI ON
New Strength
PA required
PA required
Keep non‐ formulary
Excluded (covered by Part D)
2.5 MG
TAB SUBL
SUBLIN GUAL
New Strength
Keep non‐ Keep non‐ formulary formulary
Excluded (covered by Part D)
FILGRASTIM‐ SNDZ
480MCG /0.8
SYRINGE
INJECTI ON
New Biosimliar
Excluded (FFS Medi‐ Cal Carve‐ out) PA required
PA required
Keep non‐ formulary
Excluded (covered by Part D)
FILGRASTIM‐ SNDZ
300MCG /0.5
SYRINGE
INJECTI ON
New Biosimliar
PA required
PA required
Keep non‐ formulary
Excluded (covered by Part D)
BRAND NAME
GENERIC NAME
STRENGTH
ARANESP
DARBEPOETIN ALFA IN POLYSORBAT
10MCG/ 0.4
SAPHRIS
ASENAPINE MALEATE
ZARXIO
ZARXIO
CWRAP = Medicare/Medi‐Cal
DOSAGE FORM
