1 Pharmacy Updates Summary Jan 2016 The following changes to SFHP formulary and prior authorization criteria were reviewed and approved by the SFHP P&T Committee on 10/21/2015 Effective date for all changes: 3/1/2016 Contents Therapeutic 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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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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Additional Proposed Changes to SFHP Formulary ............................................................................................................................................ 5
Interim Formulary Changes
September ........................................................................................................................................................................................... 6
October ................................................................................................................................................................................................ 8
November .......................................................................................................................................................................................... 10
December ........................................................................................................................................................................................... 13
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))
No changes (excluded)
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
No changes (excluded)
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)
No changes (excluded)
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
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
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)
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
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
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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)