Pharmacy Updates Summary - San Francisco's #1 Choice for ... · 1 Pharmacy Updates Summary Jan 2016 The following changes to SFHP formulary and prior authorization criteria were reviewed

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PharmacyUpdatesSummaryJan2016ThefollowingchangestoSFHPformularyandpriorauthorizationcriteriawerereviewedandapprovedbytheSFHPP&TCommitteeon10/21/2015 Effectivedateforallchanges:3/1/2016

ContentsTherapeutic Classes Reviewed

Urinary Antispasmodics ....................................................................................................................................................................... 2

Inhaled Corticosteroids ........................................................................................................................................................................ 3

Acne Medications ................................................................................................................................................................................ 4

Additional Proposed Changes to SFHP Formulary ............................................................................................................................................ 5

Interim Formulary Changes

September ........................................................................................................................................................................................... 6

October ................................................................................................................................................................................................ 8

November .......................................................................................................................................................................................... 10

December ........................................................................................................................................................................................... 13

Annual Prior Authorization Criteria Review .................................................................................................................................................... 20

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UrinaryAntispasmodics

Drug Name, Strength, Dosage Form Formulary Change Medi‐Cal

Formulary Change Healthy Kids

Formulary Change Medicare/Medi‐Cal

Darifenacin (Enablex) 7.5, 15 mg ER tablet Non‐formulary Non‐formulary No changes (excluded) Oxybutynin (Ditropan) 5 mg tablet Formulary Formulary No changes (excluded) Oxybutynin (Gelnique) 28 mg/0.92 g pump, 10% gel packet

Non‐formulary Non‐formulary No changes (excluded)

Oxybutynin (Oxytrol For Women/Oxytrol) 3.9 mg/24 hour TD patch

No change No change No changes (excluded)

Oxybutynin 5 mg/5 ml syrup Formulary Formulary No changes (excluded) Oxybutynin ER (Ditropan XL) 5, 10, 15 mg tablet Formulary #1 per day Formulary #1 per day No changes (excluded) Solifenacin (VESIcare) 5, 10 mg tablet Non‐formulary Non‐formulary No changes (excluded) Tolterodine (Detrol) 2, 4 mg tablet Step therapy (oxybutynin

IR/ER) #2 per day Step therapy (oxybutynin IR/ER) #2 per day

No changes (excluded)

Tolterodine ER (Detrol LA) 2, 4 mg ER capsules Step therapy (oxybutynin IR/ER #1 per day)

Step therapy (oxybutynin IR/ER #1 per day)


Trospium 20 mg tablets Step therapy (oxybutynin IR/ER #1 per day)



Trospium ER 60 mg capsules Step therapy (oxybutynin IR/ER #1 per day)



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InhaledCorticosteroids

Drug Name/Strength/Dosage Form Formulary Change Medi‐Cal



Arnuity Ellipta® inhaler 100 mcg Formulary QL #60/30 days

(2 inhalers) Formulary QL #60/30 days (2 inhalers)


200 mcg Formulary QL #60/30 days (2 inhalers)

Formulary QL #60/30 days (2 inhalers)


Asmanex® HFA inhaler 100 mcg Formulary QL #26 per 30

days (2 inhalers) Formulary QL #26 per 30 days (2 inhalers)


200 mcg Formulary QL #26 per 30 days (2 inhalers)

Formulary QL #26 per 30 days (2 inhalers)


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AcneMedicationsDrug Name/Strength/Dosage Form Formulary Change

Medi‐Cal Formulary Change Healthy Kids


Over‐the Counter (OTC) Products Benzoyl peroxide 2.5% cleanser Non‐formulary Excluded (OTC products

excluded) No change

Benzoyl peroxide 7% cleanser Non‐Formulary No change Non‐Formulary

Benzoyl peroxide 5% lotion

Formulary No change Formulary

Benzoyl peroxide 10% lotion


On‐the‐spot® (benzoyl peroxide) 2.5% cream


Benzoyl peroxide 6% cleanser

Formulary Formulary No change

Benzoyl peroxide 7% cleanser

Non‐formulary Non‐formulary No change

Benzoyl peroxide (Pacnex MX®) 4.25% cleanser

Non‐formulary Non‐formulary No change

Azelaic acid (Finacea®) 15% gel, foam

PA required PA required No change

Isotretinoin (Claravis, Amnesteem, Zenatane, Myorisan®) 10, 20, 30, 40 mg capsule

PA required PA required No change

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AdditionalProposedFormularyChangesDrug name/strength/dosage form/GCN Formulary Change



Cyclophosphamide 25, 50 mg tab Non‐formulary Non‐formulary No changes (excluded)Cyclophosphamide 25, 50 mg cap PA required PA required No changes (excluded)Cyclosporine modified 50 mg Formulary ≥21 y/o Formulary No changes (excluded)Tramadol Hcl/Acetaminophen 37.5‐325mg Tablet

Formulary #4 per day Formulary #4 per day No changes (excluded)

Mirena IUD Excluded (Excluded (Medical Benefit))

Excluded (Excluded (Medical Benefit))


Magnesium Oxide 400 mg Formulary No changes Formulary Itraconazole 100 mg capsule, 200 mg tablet PA required PA required No changes (excluded)Triazolam Non‐formulary Non‐formulary No changes (excluded)Clonazepam ODT Non‐formulary Non‐formulary No changes (excluded)Memantine (Namenda) 5, 10 mg tablet Formulary Formulary No changes (excluded)Rifapentene 150 tablet (Priftin) Formulary Formulary No changes (excluded)Permethrin 5 % topical cream Formulary #60 per 30 days x 2

fills per year Formulary #60 per 30 days x 2 fills per year


Metformin ER 750 mg tablet Formulary ≥ 21 y/o Formulary No changes (excluded)Ezetemibe (Zetia) Step therapy (atorvastatin 80

mg, cumulative 90 days supply in the last 6 months) ≥21 y/o

Step therapy (atorvastatin 80 mg, cumulative 90 days supply in the last 6 months)


Ketorolac eye drops Formulary Formulary No changes (excluded)Mycophenolate 250 mg capsule Formulary Formulary No changes (excluded)Lanreotide (Somatuline Depot) PA required PA required No changes (excluded)

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SeptemberInterimFormularyChanges

Drug name/strength/dosage form Formulary Change Medi‐Cal



Finacea 15% Foam PA Required PA Required Excluded Hycofenix 2.5‐30‐200 Solution Non‐Formulary Non‐Formulary Excluded Alternaria 20000/Ml Vial Non‐Formulary Non‐Formulary Excluded American Cockroach Extract 1:20 Vial Non‐Formulary Non‐Formulary Excluded American Elm 1:20 Vial Non‐Formulary Non‐Formulary Excluded Mixed Ragweed Extract 1:20 Non‐Formulary Non‐Formulary Excluded Sulfzix 400‐500/.4 Powder Non‐Formulary Non‐Formulary Excluded Neutrasal Powd Pack Non‐Formulary Non‐Formulary Excluded

Flumist Quad 2015‐2016 10e6.5‐7.5 Nasal Spray

Add To Formulary With Age Min 19 And Max 49 (Pays Only For Member 19 To 49 Years) And Fill Limit #1/270 Days ($24.03/Vaccine)

Non‐Formulary Excluded

Eastern Cottonwood 1:20 Vial Non‐Formulary Non‐Formulary Excluded Mountain Cedar 1:20 Vial Non‐Formulary Non‐Formulary Excluded Dog Epithelium Extract 1:10 Vial Non‐Formulary Non‐Formulary Excluded Standardized Cat Hair 10k Unit/1 Vial Non‐Formulary Non‐Formulary Excluded Glycopyrrolate 0.4mg/2ml Syringe Non‐Formulary Non‐Formulary Excluded Healon Ultimate Dual Pack 10‐23mg/Ml Syringe Non‐Formulary Non‐Formulary Excluded

Zecuity 6.5 Mg/4hr Patch Ioph Non‐Formulary Non‐Formulary Excluded Arida Gel (Gram) Non‐Formulary Non‐Formulary Excluded Clin Single Use 150 Mg/Ml Kit Non‐Formulary Non‐Formulary Excluded Single Use Ez Flu 2015‐2016 45mcg/.5ml Syringekit

Non‐Formulary ($158/Single Use Kit) Non‐Formulary Excluded

Standardized Timothy Grass 100000/Ml Vial Non‐Formulary Non‐Formulary Excluded Creatine 100% Powder Non‐Formulary Non‐Formulary Excluded Synjardy 5mg‐1000mg Tablet Non‐Formulary Non‐Formulary Excluded Synjardy 12.5‐1000 Tablet Non‐Formulary Non‐Formulary Excluded

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Synjardy 5 Mg‐500mg Tablet Non‐Formulary Non‐Formulary Excluded Synjardy 12.5‐500mg Tablet Non‐Formulary Non‐Formulary Excluded Thrivite Rx 29 Mg‐1 Mg Tablet Non‐Formulary Non‐Formulary Excluded Salicylic Acid 28.50% Liq‐Film Non‐Formulary Non‐Formulary Excluded Repatha Sureclick 140 Mg/Ml Pen Injctr PA required PA required Excluded Repatha Syringe 140 Mg/Ml Syringe PA required PA required Excluded White Oak Extract 1:20 Vial Non‐Formulary Non‐Formulary Excluded Johnson Grass 1:20 Vial Non‐Formulary Non‐Formulary Excluded D.Farinae Mite Extract 10000/Ml Vial Non‐Formulary Non‐Formulary Excluded D.Pteronyssinus Mite Extract 10000/Ml Vial Non‐Formulary Non‐Formulary Excluded Standard Bermuda Grass Pollen 10k Unit/1 Vial Non‐Formulary Non‐Formulary Excluded

Envarsus Xr 0.75 Mg Tab Er 24h Non‐Formulary Non‐Formulary Excluded Envarsus Xr 1 Mg Tab Er 24h Non‐Formulary Non‐Formulary Excluded Envarsus Xr 4 Mg Tab Er 24h Non‐Formulary Non‐Formulary Excluded Lumason 25 Mg Vial Non‐Formulary Non‐Formulary Excluded Triferic 272mg/50ml Ampul Non‐Formulary Non‐Formulary Excluded Zubsolv 11.4‐2.9mg Tab Subl Excluded (Carve Out) Non‐Formulary Excluded Zubsolv 2.9‐0.71mg Tab Subl Excluded (Carve Out) Non‐Formulary Excluded Brilinta 60 Mg Tablet Non‐Formulary Non‐Formulary Excluded Zarxio 480mcg/0.8 Syringe PA required PA required Excluded Zarxio 300mcg/0.5 Syringe PA required PA required Excluded Otrexup 7.5 Mg/0.4 Auto Injct Non‐Formulary Non‐Formulary Excluded

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OctoberInterimFormularyChanges




Cardioplegia Maintenance 8:1 36 Meq/500 Plst Bg Pf Non‐Formulary Non‐Formulary Excluded

Cardioplegia Induction 8:1 100meq/500 Plst Bg Pf Non‐Formulary Non‐Formulary Excluded

Fycompa 2 Mg‐4 Mg Tab Ds Pk Non‐Formulary Non‐Formulary Excluded Pro‐C‐Dure 5 40 Mg/Ml Kit Non‐Formulary Non‐Formulary Excluded Pro‐C‐Dure 6 40 Mg/Ml Kit Non‐Formulary Non‐Formulary Excluded Beta 1 6 Mg/Ml Kit Non‐Formulary Non‐Formulary Excluded Dermasilkrx Diclopak 75mg‐.025% Kit Non‐Formulary Non‐Formulary Excluded

Vizamyl 5 Mci (185 Mbq) Vial Excluded (Excluded (Medical Benefit))

Excluded (Excluded (Medical Benefit)) Excluded

Addyi 100 Mg Tablet Non‐Formulary Non‐Formulary Excluded Evarrest 2" X 4" (55.5 Mg‐241.9 Unit/Inch2) Adh. Patch Non‐Formulary Non‐Formulary Excluded

Evarrest 4" X 4" (55.5 Mg‐241.9 Unit/Inch2) Adh. Patch Non‐Formulary Non‐Formulary Excluded

Durlaza 162.5 Mg Cap Er 24h Non‐Formulary Non‐Formulary Excluded Magnesium Glycinate 0.2 Powder Non‐Formulary Non‐Formulary Excluded Natural Mixed Tocopherols 0.3 Powder Non‐Formulary Non‐Formulary Excluded

Spiriva Respimat 1.25 Mcg Mist Inhal Formulary #4 grams per 30 days

Formulary #4 grams per 30 days Excluded

Co‐Veratrol 200‐5‐0.8 Capsule Non‐Formulary Non‐Formulary Excluded Vitafol Fe+ 90‐1‐200mg Capsule Non‐Formulary Non‐Formulary Excluded Dermapak Plus 0.025‐.44% Kit Non‐Formulary Non‐Formulary Excluded Dermacinrx Silazone 0.001 Kit Non‐Formulary Non‐Formulary Excluded Lonsurf 15‐6.14 Mg Tablet Non‐Formulary Non‐Formulary Excluded Lonsurf 20‐8.19 Mg Tablet Non‐Formulary Non‐Formulary Excluded Odomzo 200 Mg Capsule Non‐Formulary Non‐Formulary Excluded Calcium Gluconate Monohydrate 1 Powder Non‐Formulary Non‐Formulary Excluded

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Floriva 0.25 Mg Fluoride (0.55 Mg) Tab Chew Non‐Formulary Non‐Formulary Excluded

Morphine Sulfate 4 Mg/Ml Vial Excluded (Excluded (Medical Benefit))


Morphine Sulfate 8 Mg/Ml Vial Excluded (Excluded (Medical Benefit))


Aristada 441 Mg/1.6 Ml Suser Syr Excluded (Carve Out) Non‐Formulary Excluded Aristada 662 Mg/2.4 Ml Suser Syr Excluded (Carve Out) PA required Excluded Aristada 882 Mg/3.2 Ml Suser Syr Excluded (Carve Out) PA required Excluded Episnap 1 Mg/Ml (1 Ml) Kit Non‐Formulary Non‐Formulary Excluded Ldo Plus 0.04 Gel (Ml) Non‐Formulary Non‐Formulary Excluded Whytederm Tdpak 0.1 %‐2 % Kit Non‐Formulary Non‐Formulary Excluded Calcium Amino Acid Chelate 0.3 Granules Non‐Formulary Non‐Formulary Excluded

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NovemberInterimFormularyChanges




Midazolam HCl‐0.9% NaCl 1 Mg/ml Plast. Bag Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded Varubi 90 Mg Tablet Non‐Formulary Non‐Formulary Excluded Atropine Sulfate‐0.9% NaCl 0.8 Mg/2 ml (0.4 Mg/ml) Syringe Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Phenylephrine HCl‐0.9% NaCl 50 Mg/250 ml (200 Mcg/ml) Plast. Bag Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Bivalirudin 250 Mg Vial Port Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded Dermasilkrx Lidorxkit 0.05 Cmb Ont Cr Non‐Formulary Non‐Formulary Excluded Keveyis 50 Mg Tablet Non‐Formulary Non‐Formulary Excluded Hicon 1,000 Mci/ml (1 ml) Kit Non‐Formulary Non‐Formulary Excluded Hicon 250 Mci/0.25 ml Kit Non‐Formulary Non‐Formulary Excluded Hicon 500 Mci/0.5 ml Kit Non‐Formulary Non‐Formulary Excluded Meropenem‐0.9% NaCl 500 Mg/50 ml Piggyback Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Meropenem‐0.9% NaCl 1 Gram/50 ml Piggyback Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Mugwort 0.06 Vial Non‐Formulary Non‐Formulary Excluded Red Cedar 0.06 Vial Non‐Formulary Non‐Formulary Excluded White Ash 0.06 Vial Non‐Formulary Non‐Formulary Excluded Black Walnut Pollen 0.06 Vial Non‐Formulary Non‐Formulary Excluded Lamb's Quarters 0.06 Vial Non‐Formulary Non‐Formulary Excluded Shagbark Hickory 0.06 Vial Non‐Formulary Non‐Formulary Excluded Sheep Sorrel‐Yellow Dock 0.06 Vial Non‐Formulary Non‐Formulary Excluded Rough Pigweed 0.06 Vial Non‐Formulary Non‐Formulary Excluded English Plantain 0.06 Vial Non‐Formulary Non‐Formulary Excluded Bahia 0.06 Vial Non‐Formulary Non‐Formulary Excluded Mesquite 0.06 Vial Non‐Formulary Non‐Formulary Excluded American Sycamore 0.06 Vial Non‐Formulary Non‐Formulary Excluded Bayberry 0.06 Vial Non‐Formulary Non‐Formulary Excluded

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Suprax 400 mg capsule Formulary #28 per 28 days Formulary #28 per 28 days No changes (excluded) Suprax 400 mg tablet Non‐formulary Non‐formulary No changes (excluded) Box Elder 0.06 Vial Non‐Formulary Non‐Formulary Excluded Russian Thistle 0.06 Vial Non‐Formulary Non‐Formulary Excluded Sagebrush 0.06 Vial Non‐Formulary Non‐Formulary Excluded Red Birch 0.06 Vial Non‐Formulary Non‐Formulary Excluded Virginia Live Oak 0.06 Vial Non‐Formulary Non‐Formulary Excluded Candida Albicans 20,000 Unit/ml (1:10 W/V) Vial Non‐Formulary Non‐Formulary Excluded

Pecan Pollen 0.06 Vial Non‐Formulary Non‐Formulary Excluded Horse Epithelium 0.06 Vial Non‐Formulary Non‐Formulary Excluded Fusion Sprinkles 7mg‐250mcg Powd Pack Non‐Formulary Non‐Formulary Excluded Methazel 1‐50‐2.5mg Capsule Non‐Formulary Non‐Formulary Excluded Restora Sprinkles 15‐0.25 Mg Powd Pack Non‐Formulary Non‐Formulary Excluded Praxbind 2.5 G/50ml Vial Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded Tolak 0.04 Cream (G) Non‐Formulary Non‐Formulary Excluded Tresiba Flextouch U‐100 100 Unit/ml (3 ml) Insuln Pen Non‐Formulary Non‐Formulary Excluded

Tresiba Flextouch U‐200 200 Unit/ml (3 ml) Insuln Pen Non‐Formulary Non‐Formulary Excluded

Celacyn Post Procedure 0 Cmb Gel Sp Non‐Formulary Non‐Formulary Excluded Nuwiq 250 (+/‐) Unit Range Vial Carve Out Non‐Formulary Excluded Nuwiq 500 (+/‐) Unit Range Vial Carve Out Non‐Formulary Excluded Nuwiq 1,000 (+/‐) Unit Range Vial Carve Out Non‐Formulary Excluded Nuwiq 2,000 (+/‐) Unit Range Vial Carve Out Non‐Formulary Excluded Onivyde 43 Mg/10 ml (4.3 Mg/ml) Vial Non‐Formulary Non‐Formulary Excluded Yondelis 1 Mg Vial Non‐Formulary Non‐Formulary Excluded Imlygic 10exp6 (1 Million) Pfu/ml Vial Non‐Formulary Non‐Formulary Excluded Imlygic 10exp8 (100 Million) Pfu/ml Vial Non‐Formulary Non‐Formulary Excluded Fluconazole‐NaCl 100 Mg/50 ml Piggyback Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded Strensiq 40 Mg/ml Vial Non‐Formulary Non‐Formulary Excluded

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Strensiq 80 Mg/0.8 ml Vial Non‐Formulary Non‐Formulary Excluded Strensiq 18 Mg/0.45 ml Vial Non‐Formulary Non‐Formulary Excluded Strensiq 28 Mg/0.7 ml Vial Non‐Formulary Non‐Formulary Excluded Dermacinrx Purefolix 5,000 Unit‐1 Mg Tablet Non‐Formulary Non‐Formulary Excluded Glycopyrrolate 0.6 Mg/3 ml (0.2 Mg/ml) Syringe Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

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DecemberInterimFormularyChangesDrug name/strength/dosage form Formulary Change



Nicardipine hcl‐0.9% nacl1 mg/10 ml Syringe Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Seebri neohaler15.6 mcgCap w/dev Non‐Formulary Non‐Formulary Excluded

Hydromorphone hcl‐0.9% nacl2 mg/mlPlast. Bag

Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Flexepax10 mg‐0.0375 %‐5 %Cmb tabpat Non‐Formulary Non‐Formulary Excluded

Neostigmine methylsulfate3 mg/3 ml (1 mg/ml)Syringe






Epinephrine hcl‐0.9% nacl50 mcg/5 ml (10 mcg/ml)Syringe


Utibron neohaler27.5 mcg‐15.6 mcgCap w/dev Non‐Formulary Non‐Formulary Excluded

PediapalmSpray Non‐Formulary Non‐Formulary Excluded

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Heparin sodium‐0.9% nacl1,000 unit/1,000 ml (1 unit/ml)Iv soln


Heparin sodium‐0.9% nacl6,000 unit/1,000 ml (6 unit/ml)Iv soln


Pedipak8 %‐20 %Kt crm lq Non‐Formulary Non‐Formulary Excluded

Napropax500 mg‐0.0375 %‐5 %Cmb tabpat Non‐Formulary Non‐Formulary Excluded

Gleostine5 mgCapsule Non‐Formulary Non‐Formulary Excluded

Cotellic20 mgTablet Non‐Formulary Non‐Formulary Excluded

Cefazolin sodium‐0.9% nacl2 gram/50 mlPiggyback


Cefazolin sodium‐dextrose2 gram/100 mlFroz.piggy


Genvoya150 mg‐150 mg‐200 mg‐10 mgTablet Carve out Non‐Formulary Excluded

Ez flu 2015‐2016 (fluvirin)45 mcg (15 mcg x 3)/0.5 mlSyringekit

Non‐Formulary; awp $187.00

Non‐Formulary; awp $187.00 Excluded

Nucala100 mgVial Non‐Formulary Non‐Formulary Excluded

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Dyzbac25 mg‐150 mg‐50 mg‐1 mg‐12.5 mg‐1 mg‐125 mg‐500 unitTablet

Non‐Formulary Non‐Formulary Excluded

Viberzi75 mgTablet Non‐Formulary Non‐Formulary Excluded

Viberzi100 mgTablet Non‐Formulary Non‐Formulary Excluded

Bupivacaine hcl0.5 % 400 mlEls pmp hr Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Ropivacaine hcl0.2 % 400 mlEls pmp lr Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Midazolam hcl5 mg/5 ml (1 mg/ml)Syringe Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Hydromorph‐bupivac‐0.9% nacl20 mcg/ml‐0.1 %Pump resvr


TetrixCream (g) Non‐Formulary Non‐Formulary Excluded

Napropak cool550 mg‐4 %Kit Non‐Formulary Non‐Formulary Excluded

Tagrisso40 mgTablet Non‐Formulary Non‐Formulary Excluded

Tagrisso80 mgTablet Non‐Formulary Non‐Formulary Excluded

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Darzalex100 mg/5 ml (20 mg/ml)Vial Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Darzalex400 mg/20 ml (20 mg/ml)Vial Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Vancomycin hcl‐0.9% nacl750 mg/250 mlPlast. Bag


Standard rye grass pollen100,000 bioequiv. Allergy unit/mlVial


Veltassa8.4 gramPowd pack Non‐Formulary Non‐Formulary Excluded



Bupivacaine hcl0.25 % 5 ml/hour 270 mlEls pmp fr


Belbuca75 mcgFilm Non‐Formulary Non‐Formulary Excluded



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Truskin2 cm x 4 cmSheet Non‐Formulary Non‐Formulary Excluded

Truskin4 cm x 8 cmSheet Non‐Formulary Non‐Formulary Excluded

Adynovate250 (+/‐) unit rangeVial Carve out Non‐Formulary Excluded

Adynovate500 (+/‐) unit rangeVial Carve out Non‐Formulary Excluded

Adynovate1,000 (+/‐) unit rangeVial Carve out Non‐Formulary Excluded

Adynovate2,000 (+/‐) unit rangeVial Carve out Non‐Formulary Excluded

Coagadex250 (+/‐) unit rangeVial Carve out Non‐Formulary Excluded

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Coagadex500 (+/‐) unit rangeVial Carve out Non‐Formulary Excluded

Ninlaro2.3 mgCapsule Non‐Formulary Non‐Formulary Excluded

Ninlaro3 mgCapsule Non‐Formulary Non‐Formulary Excluded

Ninlaro4 mgCapsule Non‐Formulary Non‐Formulary Excluded

Ketoconazole1Crystals Non‐Formulary Non‐Formulary Excluded

Methaver27 mg‐29 mg‐50 mg‐1 mg‐2 mgCapsule

Non‐Formulary Non‐Formulary Excluded

Ferriprox100 mg/mlSolution Non‐Formulary Non‐Formulary Excluded

Narcan4 mg/actuationSpray Excluded (carve‐out) Non‐Formulary Excluded

Whytederm surgipak2 %‐4 %‐2 %Kit Non‐Formulary Non‐Formulary Excluded

Makena250 mg/mlVial Updated gcn 12‐4‐15 Updated gcn 12‐4‐15 Excluded

Vivlodex5 mgCapsule Non‐Formulary Non‐Formulary Excluded

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Vivlodex10 mgCapsule Non‐Formulary Non‐Formulary Excluded

Empliciti300 mgVial Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

Empliciti400 mgVial Excluded (Medical Benefit) Excluded (Medical Benefit) Excluded

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AnnualPriorAuthorizationCriteriaReview SFHP conducts an annual prior authorization criteria review as part of organization’s quality improvement initiatives. Full length prior authorization criteria document can be found on SFHP’s website at http://www.sfhp.org/providers/formulary/prior‐authorization‐requests/.

The following is a summary of changes to SFHP’s prior authorization criteria made to address review findings and needs for new criteria identified as part of the prior authorization review process:

Revisions were made to the prior authorization criteria for following drugs class classes and individual medications: Drug class/Medication Revisions summaryAll drug classes/medications Under Quantity Limit column, indicated therapeutic classes where 90 days supply is allowed for

brand medications used for maintenance treatment of chronic conditions Listed formulary status for all medications within the drug class Arranged criteria listing by therapeutic/pharmacological class

Acyclovir ointment Decreased quantity limit from 15 grams to 5 grams per 30 days Antihistamines, 2nd generation Removed requirement for trial and failure with intranasal antihistamines Allergic conjunctivitis Added criteria for non‐formulary medications Cardio agents (antiplatelet agents, ARBs, carvedilol, ranolazine)

Added age limit for coordination of benefit with California Children’s Services (CCS)

Cardio: Anticoagulants: LMWH/FactorXa Inhibitor, injectable (Lovenox, etc)

Removed requirement of hematologist or oncologist for prevention and/or treatment of a venous thromboembolism (VTE), a proximal DVT and/or PE for patients with cancer (commonly prescribed by PCPs)

CNS stimulants (modafinil, etc) Added requirement of sleep study confirming diagnosis of narcolepsy CNS stimulants: ADHD medications Developed criteria for non‐formulary medications with requirement of trial and failure or inability to

use preferred medications Replaced “prescribed by a psychiatrist” language with “prescribed or recommended by a

psychiatrist” Contraceptives, Oral Created criteria for continuous cycle dosing (#112 per 84 days) if medically necessary or needed due

to history of non‐compliance Deferasirox (Exjade, Jadenu) Added indication of chronic iron overload in non‐transfusion dependent thalassemia syndromes

Removed requirement for “treatment failure, contraindication or significant intolerance to deferoxamine treatment” from indication of chronic iron overload due to blood transfusions

Changed duration of approval to 12 months from 3 months Diabetes agents Added age limit for coordination of benefit with California Children’s Services (CCS)

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Drug class/Medication Revisions summaryDisease Modifying Biologics (e.g. Enbrel, Humira)

Updated age cut‐offs to align with prescribing information (e.g. 6 y/o for Crohn’s disease) Added requirement for preferred medications for each indication (e.g. Humira and/or Enbrel) Added QuantiFERON®‐TB Gold test as example of TB testing Added Otezla and Cosentyx to the list of non‐formulary medications Extended duration of approval to 2 years for re‐authorization requests

Dronabinol Added indication of HIV medication associated nausea/vomiting (in addition to HIV associated nausea/vomiting)

Endocrine: Growth Hormone GHD indication: o Added reference range for pediatric subnormal GH response to provocative stimulation test

(GH response < 10 mg/mL) o Added height velocity < 25th percentile as one of the options for confirming diagnosis of GHD

Growth Failure due to Chronic Renal Insufficiency: removed requirement for renal transplantation (not required for use, additionally use of rhGH in pediatric renal allograft recipients not approved indication)

Enteral Nutrition Products Changes made to align with SFHP UM criteria o Defined approval criteria for children 12‐24 months as weight ≤ 3rd percentile o Defined approval criteria for children and adolescent 2 years of age through 20 years of age as

weight ≤ 5th percentile Revised re‐authorization section to evaluate whether continuation of therapy is medically necessary

(e.g. weight still below goal or therapy is needed to maintain healthy weight) Epogen/Procrit/Aranesp Extended approval duration from 3 months to 12 months Fenofibrate (non‐formulary products) Added age requirement to coordinate benefit with California Children’s Services (CCS)

Updated criteria to only require trial and failure or inability to use formulary fenofibrate products (previously required statins and other agents)

Filgrastim (Neupogen®) Pegfilgrastim (Neulasta®)

Created re‐authorization criteria (patient is still receiving chemotherapy) Entered quantity limits

Hydroxyprogesterone caproate 250 mg/mL intramuscular oil (Makena)

Allowed for current gestational age to be provided with request instead of expected delivery date

Infectious Disease: Antifungals, Azole Updated criteria for voriconazole Created criteria for itraconazole, posaconazole and isavuconazonium (Cresemba)

Lamictal XR Updated quantity limit from #2 per day to #1 per day Long‐acting opiates

For inability to use morphine sulfate ER tablets, added example of “previous history of opiate tablet abuse”

Inability to use fentanyl now includes example of “available fentanyl strengths are not equivalent to

22

Drug class/Medication Revisions summarythe requested regimen; requested regimen is equivalent to less than 60 mg of morphine daily”

Memantine (Namenda) Removed criteria for IR product Added criteria for XR and solution formulations Extended duration of approval to 2 years

Multiple Sclerosis Extended duration of approval to 2 years on re‐authorization Niacin (non‐formulary products) Changed requirement from trial and failure or inability to use 3 preferred agents to 2 preferred

agents Omega‐3 fatty acids Changed requirement from trial and failure or inability to use 3 preferred agents to 2 preferred

agents Added Vascepa

Oncology: Lenalidomide (Revlimid)

Multiple Myeloma: removed requirement of one prior chemotherapy to reflect standard practice and chemo‐ineligible treatment

Added Mantle Cell Lymphoma indication Oncology: Enzalutamide (Xtandi®) Removed requirement that “patient is male” as already require diagnosis of metastatic prostate

cancer Oncology: Erlotinib (Tarceva) Removed requirement for use as monotherapy in cases where there is no disease progression after

four cycles of first‐line platinum chemotherapy Oncology: Everolimus (Afinitor®, Afinitor® Disperz)

For renal cell carcinoma indication, added requirement for trial/failure/intolerance to ONE prior tyrosine kinase inhibitor

Oncology: Imatinib (Gleevec) Changed Pediatric Indications age requirement to ≥1 year to reflect product labeling Oncology: Ponatinib (Inclusig) Added option of confirmation of T315I mutation to reflect label indication Ophthalmic Prostaglandins Analogues Travoprost: increased duration of approval to 2 years, modified to reflect step therapy with

Latanoprost Non‐formulary agents: added requirement for trial and failure with latanoprost AND travoprost or

allergy to benzalkonium chloride Phosphate Binders Added new product Auryxia PPIs Updated formulary status for rabeprazole Promacta (Eltrombopag) Removed requirement for diagnosis of chronic ITP to be > 3 months duration Pulmonary: Cystic Fibrosis Kalydeco & Orkambi

Orkambi: added contraindication when AST or ALT is 5 times ULN (due to ivacaftor) Kalydeco & Orkambi: for continuation of therapy, added requirement of AST/ALT from within last

year Rifaximin (Xifaxan) Increased quantity limit for indication of SIBO Short‐acting beta2 agonist criteria Developed criteria for albuterol sulfate ER tablets

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Drug class/Medication Revisions summaryTopical Antiparasitics Added criteria for quantities over quantity limit (i.e. 2 applications) Topical calcineurin inhibitors Removed diagnosis requirement as products have many accepted off‐label uses Topical NSAIDs Replaced requirement for use of capsaicin topical products with Voltaren 1% gel Topical steroids Changed requirement for trial and failure or inability to use ALL formulary medications in the same

potency group to TWO formulary medications Fixed error of placement of fluocinonide cream in potency group 2 Obtained expert medical review (via MRIoA) to confirm that formulary and prior authorization

criteria adequately reflect appropriate clinical practice Triptans Developed new criteria for non‐formulary medications with requirement of trial and failure or

inability to use preferred medications Vitamin D analogs Extended authorization duration to 2 years 2nd generation antihistamines Removed requirement for intranasal steroids Enteral Nutrition Products

Auth period extended from 6 months to indefinite where chronic tube feeding is needed (e.g. short gut syndrome, severe cerebral palsy or other chronic encephalopathy)

Colchicine (Colcrys)

Removed requirement for trail and failure or inability to use NSAIDs for treatment of acute and chronic gout

Updated auth duration from 6 to12 months for acute gout prophylaxis during urate lowering therapy initiation

Ciprofloxacin/Dexamethasone (Ciprodex)

Removed “OR patient has inflammation, pruritus or ear pain” language; criteria now state “trial and failure or intolerance to ciprofloxacin or ofloxacin otic solution”

Specialty Infant Enteral Nutrition Products

Low birth weight definition changed from 3500 to 2500 grams Added requirement for inability to use non‐cow’s milk protein‐based formula (e.g. soy‐based) for

Alimentum, Pregestimil and Nutramigen products

New prior authorization criteria were developed for the following drug classes and individual medications: o Anorexiants o Benzodiazepines o Ceritinib (Zykadia™) o Dronedarone (Multaq) o Fluocinolone acetonide 0.01% otic oil (Dermotic) o Lactobacillus

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o Laxatives (Amitizia, Linzess) o Lamotrigine ER o Levothyroxine capsules (Tirosint) o Leukotriene Modifiers o Mesalamine enema kit (Rowasa) o Metformin ER (Glumetza, Fortamet) o Migraine: miscellaneous agents o Mupirocin 2% ointment (Bactroban) o Namenda XR o Nitroglycerin 0.4% ointment (Rectiv) o Onychomychosis o Ophthalmic Prostaglandin Analogs o Pancreatic Enzymes o Potassium formulations o Renin inhibitors o Rifapentin (Priftin) o Short‐acting opiates o Teriparatide (Forteo) o Vilazodone (Viibryd)

Documents

Pharmacy Updates Summary - San Francisco's #1 Choice for ... · 1 Pharmacy Updates Summary Jan 2016 The following changes to SFHP formulary and prior authorization criteria were reviewed