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San Francisco Health Plan (SFHP) The following changes to SFHP formulary and prior authorization criteria were reviewed and approved by the SFHP Pharmacy and Therapeutics (P&T) Committee on 07/19/2017.
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San Francisco Health Plan (SFHP) The following changes to SFHP formulary and prior authorization criteria were reviewed and approved by the SFHP Pharmacy and Therapeutics (P&T) Committee on 07/19/2017. Effective date for all changes is 08/20/2017. SFHP formulary can be accessed at and prior authorization criteria at Contents Gastrointestinal: Irritable Bowel Syndrome... 2 Gastrointestinal: Ulcerative Colitis/Crohn s Disease... 2 Gastrointestinal: Anti-spasmodics... 2 Gastrointestinal: Anorexia/Weight Gain... 2 Gastrointestinal: Bile Salts... 2 Gastrointestinal: Ammonia Inhibitors... 2 Gastrointestinal: Pancreatic Enzymes... 3 Gastrointestinal: Antiemetics... 3 Gastrointestinal: Miscellaneous GI Medications... 3 Gastrointestinal: Gattex... 3 Gastrointestinal: Xermelo... 3 Ophthalmologic: Glaucoma... 4 Ophthalmologic: Mydriatics... 4 Ophthalmologic: Cystaran... 4 Dermatologic: Topical Immunomodulators... 4 Dermatologic: Miscellaneous Derm Medications... 4 Dermatologic: Eucrisa... 4 Topical Otic: Antibiotic-Steroid Preparations... 5 Miscellaneous Formulary Changes...6 Miscellaneous Prior Authorization Criteria Updates...6 No new criteria or revisions - miscellaneous... 6 Interim Formulary Changes (4/24/17-7/7/17)...6 New Drugs to Market... 8 Drug Class Reviews Gastrointestinal: Irritable Bowel Syndrome Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco Removed prior authorization from Linzess to align with guidelines and due to preferred pricing. Prior Authorization Criteria Update: Updated criteria to reflect formulary status of Linzess Added new criteria for alosetron based on indication and guidelines Gastrointestinal: Ulcerative Colitis/Crohn s Disease Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco Added Cortifoam to formulary (T-2) Removed quantity limits from all formulary 5-ASAs oral and rectal preparations Removed branded Apriso, Delzicol and Uceris from formulary and prior authorization due to limited utilization Prior Authorization Criteria Update: Removed PA criteria for budesonide and Uceris Gastrointestinal: Anti-spasmodics Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco Removed atropine 0.05 mg/ml syringe from formulary due to zero utilization Removed chlordiazepoxide/clidinium from formulary with grandfathering Removed chlordiazepoxide/clidinium from prior authorization criteria Gastrointestinal: Anorexia/Weight Gain Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers No changes made to formulary Added new criteria for oxandrolone requiring appropriate diagnosis. Gastrointestinal: Bile Salts Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco Added ursodiol 500 mg tablet to formulary (T-1) Added Cholbam and Ocaliva to formulary with prior authorization (T-3). Added new criteria for Cholbam and Ocaliva Gastrointestinal: Ammonia Inhibitors Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco No changes made to formulary Gastrointestinal: Pancreatic Enzymes Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers, and Healthy San Francisco Added Creon (lipase/protease/amylase) k DR capsule to formulary (T-2) due to preferred pricing Removed quantity limits from Creon and Zenpep due to preferred pricing Updated criteria for Digestive Enzymes to reflect formulary changes. Gastrointestinal: Antiemetics, Removed Cesamet and Tigan from formulary and removed prior authorization due to zero utilization Added Transderm-Scop to formulary with prior authorization (T-3) to align with current criteria Added diagnosis and coverage criteria for PONV to Antiemetic/Antivertigo Agents Criteria (for aprepitant and netupitant/palonosetron) Gastrointestinal: Miscellaneous GI Medications (excluding where OTC exclusion applies) Added the following to formulary due to utilization and cost-effectiveness o lansoprazole capsule Rx (T-1) o Nexium capsule OTC (T-2) Removed the following due to availability of lower cost formulary alternatives and grandfathered current users: o Ranitidine capsule (Rx), 150mg and 300mg o Protonix granule packet Added Age Limit requirement to the following due to availability of lower cost formulary alternatives: o Famotidine oral suspension o Ranitidine oral suspension Added Quantity Limit requirement to the following due to excessive quantity fills o Loperamide (Imodium) 2mg capsule (Rx), 30 capsules per 30 days o Loperamide (Imodium) 2mg capsule (OTC), 30 capsules per 30 days Updated criteria for Proton Pump Inhibitors to reflect formulary changes Gastrointestinal: Gattex Keep non-formulary due to lack of utilization Gastrointestinal: Xermelo Keep non-formulary due to lack of utilization Ophthalmologic: Glaucoma Added bimatoprost 0.3% to formulary (T-1) Added Alphagan P 0.1% to formulary (T-2) Added Combigan to formulary (T-2) Removed Iopidine from formulary due to no utilization and limited place in therapy Removed carteolol and metipranolol from formulary due to being obsolete Removed travoprost (with benzalkonium) 0.004% eye drops from criteria due to product being obsolete Ophthalmologic: Mydriatics Remove Paremyd from formulary due to zero utilization Remove tropicamide 0.5% eyedrops from formulary due to zero utilization Ophthalmologic: Cystaran Keep non-formulary due to lack of utilization Dermatologic: Topical Immunomodulators No changes made to formulary Dermatologic: Miscellaneous Derm Medications Added calcipotriene 0.005% topical solution to formulary (T-1) due to cost-effectiveness comparable to alternative formulations, with Quantity Limit 60 milliliters per 30 days Removed Condylox gel from formulary due to availability of lower cost formulary alternative with comparable safety/efficacy Updated criteria for Vitamin D Analogs to reflect formulary changes Dermatologic: Eucrisa Keep non-formulary due to lack of utilization, unclear efficacy versus available alternatives, and cost. Topical Otic: Antibiotic-Steroid Preparations Formulary Update: Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco Remove Stepped Therapy edit for Ciprodex due to utilization and evidence for efficacy versus alternatives Updated criteria for Otic Antibiotics to reflect formulary changes. Formulary and Prior Authorization Criteria Updates Miscellaneous Formulary Changes Medication Formulary Change Rationale Anoro Ellipta (Umeclidinium bromide/vilanterol) mcg inhaler NF F-ST No comparable combination LABA/LAMA for COPD GOLD B, C, and D groups Applies to Medi-Cal, Healthy Kids, Healthy Workers, Healthy San Francisco formularies; Medi-Cal/Medicare formulary excluded F = Formulary, no restrictions; F-ST = Formulary, step therapy; F-QL = Formulary, quantity limit applies; F-PA = Formulary, PA required; NF = Non-formulary; Miscellaneous Prior Authorization Criteria Updates No new criteria or revisions - miscellaneous Interim Formulary Changes (4/24/17-7/7/17) Therapeutic class Medication Formulary Status Comment Urinary Tract Antispasmodic/Antiincontinence Gelnique 100 mg/gram (10 %) transdermal gel pump T3 New dosage form Agent Antineoplastic Systemic Enzyme Inhibitors Zejula 100 mg capsule T3 New Entity Antineoplastic Systemic Enzyme Inhibitors Rydapt 25 mg capsule T3 New Entity Antineoplastic Systemic Enzyme Inhibitors Alunbrig 30 mg tablet T3 New Entity Narcotic Antagonists Narcan 2 mg/actuation nasal spray Medi-Cal: CO New Strength HK:F HW: T2 Antineoplastic Anti-androgenic Agents Zytiga 500 mg tablet T3 New Entity Antineoplastic Combination - Kinase and Kisqali Femara Co-Pack 200 mg/day(200 mg x 1)-2.5 mg, 400 T3 New Combination Aromatase Inhibitors mg/day(200 mg x 2)-2.5 mg & 600 mg/day (200 mg x 3)-2.5 mg tablet Anti-inflammatory, Selective Co-stimulation Modulators, T-cell Inhibitors Orencia 50 mg/0.4 ml & 87.5 mg/0.7 ml subcutaneous syringes* T4 New Strength 6 Formulary and Prior Authorization Criteria Updates Therapeutic class Medication Formulary Status Comment Antineoplastic Systemic Enzyme Inhibitors Rubraca 250 mg tablet T3 Antivirals, HIV-specific, CCR5 Co-receptor Antagonists Antivirals,HIV-1 integrase Strand Transfer Inhibitors Selzentry 20 mg/ml oral solution Isentress HD 600 mg tablet Medi-Cal: CO HK:T3 HW: T2 Medi-Cal: CO HK:T3 HW: T2 Metallic Poison, Agents to Treat Jadenu Sprinkle 90, 180 & 360 mg oral granules in packet Medi-Cal: T4 HK:T3 HW: T2 T1 T2 T3 T4 Status Definition Formulary Drug, Generic (can have quantity Drug is a generic and is covered at point of sale if quantity limits, age, gender, and other code limits, age, gender and other code 1 restrictions 1 restrictions are met (NOTE: If quantity limits, age, gender, and other code 1 restrictions are as defined by Medi-Cal) not met, drug may still be covered through Prior Authorization process). Formulary Drug, Brand (can have quantity limits, age, gender and other code 1 restrictions) Formulary Drug, Step Therapy or Prior Authorization required Formulary Specialty Drug, Prior Authorization required Drug is a brand and is covered at point of sale if quantity limits, age, gender, and other code 1 restrictions are met (NOTE: If quantity limits, age, gender, and other code 1 restrictions are not met, drug may still be covered through Prior Authorization process). Drug is a brand or generic and is covered through Prior Authorization process or at point of sale if step therapy criteria are met. Drug requires distribution through a specialty pharmacy or is a limited distribution drug (LDD). Prior authorization process is required. Drug is non-formulary, provided through a medical benefit or excluded. Non-formulary drugs T5 Non-Formulary Drug may be covered through Prior Authorization process. Excluded drugs (e.g. FFS Medi-Cal) are not covered. All changes apply to Medi-Cal, Healthy Kids, Healthy Workers and Healthy San Francisco formularies unless otherwise indicated. *Applies to Medi-Cal formulary only. FFS Carve Out=CO Excluded= X All products are excluded for Medicare/Medi-Cal. T3 &4 products are NF for HSF The following new products are not listed in above table: Bulk chemicals (excluded from benefit) Products that are not FDA approved including emollients (excluded from benefit) Topical anti-inflammatory/analgesic combination kits (NF if separate ingredient products are available on formulary and/or available as OTC) Local anesthetics ( NF if formulary agents are available) New Strength New Strength and Dosage Form New Strength New Dosage Form 7 Formulary and Prior Authorization Criteria Updates New Drugs to Market Therapeutic class Medication Formulary Comment Adrenergics, Aromatic, Non-Catecholamine Vyvanse (lisdexamfetamine) 10, 20, 30, 40, 50, 60mg NF New dosage form; Vyvanse non-formulary chew tab Analgesics, Narcotics Arymo (morphine sulfate) ER 15, 30, 60 mg ER tab, crush resist. NF New dosage form; formulary morphine sulfate ER tablets available Antidiarrheal-Tryptophan Hydroxylase Inhibitor Xermelo (telotristat ethyl) 250 mg tablet NF New entity; formulary alternatives available Antihistamines - 1st Generation RyVent (carbinoxamine maleate) 6 mg tablet NF New strength Antihypertensives, ACE Inhibitors Epaned (enalapril) 1 mg/ml oral solution NF New strength; enalapril tab on formulary Antivirals, HIV-Specific, CCR5 Co-Receptor Antagonist Selzentry (maraviroc) 25, 75 mg tablet MCAL: CO HW: F HK: F-PA HSF: NF Cephalosporins - 1st Generation Daxbia (cephalexin) 333 mg capsule NF New strength New Strength, class is FFS Medi-Cal carve-out Glucocorticoids Emflaza (deflazacort) 6, 18, 30, 36mg tab, 22.75mg/ml NF New entity susp Glucocorticoids ZonaCort (dexamethasone) 1.5 mg 7, 11 day pack NF New dosage; generic dexamethasone on formulary IBS-C/CIC Agents, Guanylate Cyclase-C Linzess 72 mcg capsule F-PA New strength; other strengths require PA Agonist IBS-C/CIC Agents, Guanylate Cyclase-C Trulance (plecanatide) 3 mg tablet NF New entity; formulary alternatives available Agonist Influenza Virus Vaccines Flulaval Quad (PF) 60 mcg/0.5 ml IM NF New entity, flu season ended syringe Nasal Antihistamine and Anti-Inflammatory Steroid Combination Ticalast (azelastine/fluticasone) mcg nasal spray kit NF New combination; formulary alternatives available as separate ingredients Prenatal Vitamin Preparations PrimaCare 30 mg-1 mg-300 mg capsule NF New strength; formulary alternatives available Prenatal Vitamin Preparations Prenatal Plus DHA 27 mg iron-1 mg-312 mg-250 mg pack NF New combination; formulary alternatives available Rosacea Agents, Topical Rhofade (oxymetazoline hydrochloride) 1 % topical NF New Strength, Route and Dosage Form cream Topical Anti-Inflammatory Phosphodiesterase-4 (PDE4) Inhibitor Eucrisa (crisaborole) 2 % topical ointment NF New entity for atopic dermatitis; formulary alternatives available Topical Anti-Inflammatory Steroidal Ellzia Pak (triamcinolone acetonide) 0.1 %-5 % topical NF New Combination kit, ointment and cream Topical Local Anesthetics Zeyocaine (lidocaine) 5% kit (ointment and tape) NF New dosage form; formulary alternatives available 8 Formulary and Prior Authorization Criteria Updates Therapeutic class Medication Formulary Comment Fluoride preps (excluding vitamin comb.) Fluoridex paste 1.1% (sodium fluoride) F New Generic F = Formulary, no restrictions, F-QL = Formulary, quantity limit applies, F-AL = Formulary, age limit applies, F-ST = Formulary, Step Therapy, F-PA = Formulary, Prior Authorization, NF = Non-formulary, CO = carve-out 9
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