Pharmacy Updates Summary

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1 All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 01/21/2015 Effective date: 02/21/2015 Therapeutic Classes reviewed: Allergen-Specific Immunotherapy Allergic rhinitis Leukotriene Modifiers Ophthalmic steroids Oral antihistamines Prior Authorization Criteria Updates Acyclovir cream and ointment Allergen-Specific Immunotherapy Allergic rhinitis Aprepitant Azelaic Acid Biologics Calcipotriene Colchicine Dronabinol Duloxetine Eltrombopag Leukotriene Modifiers Long Acting Beta Agonists Ophthalmic steroids Oral antihistamines Pregabalin Topical NASIDs Topical retinoids Policies/Forms Approved None

2 Approved Changes: Allergen-Specific Immunotherapy Timothy Grass Pollen Extract 2,800 BAU sublingual tablet (Grastek ) Short Ragweed Pollen Extract 12 Amb a 1-unit sublingual tablet (Ragwitek ) Mixed Allergen Extract, 300 IR sublingual tablet (Oralair ) Non-formulary Non-formulary Non-formulary Non-formulary Non-formulary Non-formulary

3 Oral Antihistamines Cetirizine (Zyrtec ) Desloratadine (Clarinex ) Fexofenadine (Allegra ) 5 mg chew tabs (OTC) 10 mg chew tab (OTC) 2.5 mg [Reditabs] 5 mg tab 5 mg [Reditabs] 2.5 mg/5 ml 30 mg tabs (OTC+Rx) 60 mg tabs (OTC+Rx) 180 mg tabs 5 mg chew tab: Nonformluary w/gf Non-formulary for all except 5 mg tab (keep PA required) mg: Nonformulary w/gf Non-formulary for all except 5 mg tab (keep PA required) mg: Nonformulary w/gf for Rx; no changes for OTC 5 mg chew tab: Nonformluary w/gf mg: Nonformulary w/gf for OTC; no changes for Rx Fexofenadine pseudoephedrine (Allegra-D ) mg (OTC) mg (OTC) 180 mg: no changes mg Non- 180 mg: no changes 180 mg: no changes mg Non- Levocetirizine (Xyzal ) Loratadine pseudoephedrine (Claritin-D / Alavert- D ) 5 mg tab (Rx) 2.5mg/5 ml mg (OTC) mg (OTC) mg: Nonformulary mg: mg: Nonformulary 5 mg: #30 5 mg: #30 per 30 per mg: mg: Nonformulary

4 Leukotriene Modifiers Montelukast (Singulair ) 4 mg granule pack* Zileuton (Zyflo ) 600 mg tablet Zileuton CR (Zyflo CR) 600 mg CR tablet Non-formulary Non-formulary Non-formulary Non-formulary Allergic rhinitis Intranasal Antihistamines / Anticholinergic/ Decongestants Azelastine** 137 mcg/spray #30 ml per 30 #30 ml per 30

5 Oxymetazoline** 0.05% (30 ml) Non-formulary Non-formulary Non-formulary Intranasal Corticosteroids Mometasone ** (Nasonex 50 mcg) Triamcinolone** (Nasacort AQ ) Non formulary Non formulary Non ; self grandfather current utilizers Fluticasone #16 per 30 Non ; self grandfather current utilizers #16 per 30 Ophthalmic Steroids Difluprednate (Durezol ) ophthalmic emulsion: 5mL 0.05% Step therapy with Use fluorometholone 0.1% susp, #5 ml per 30, age limit > 21 y/o Step therapy with Use fluorometholone 0.1% susp, #5 ml per 30, age limit > 21 y/oqq Dexamethasone 0.7mg

6 (Ozurdex ) intraocular implant monohydrate 50 mg capsule monohydrate 100 mg capsule monohydrate 100 mg tablet Hyclate 100 mg tablet Hyclate 50 mg capsule Hyclate 100 mg capsule Other doxycycline monohydrate and liquid doxycycline Non-formulary Non-formulary

7 formulations Interim Changes Citranatal 90DHA Non-formulary Non-formulary No changes (NDC ) Citranatal 90DHA #60 per 30 #60 per 30 (Rx) (NDC ) Makena Non-formulary Non-formulary No changes No changes Zenpep 40K-136 K GCN *changes effective 02/21/15 CWRAP = Medicare/Medi-Cal #150 per 30 #150 per 30

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