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 7/16/2014 Effective date: 8/15/2014 Therapeutic Classes reviewed: Hepatitis C Ophthalmic Prostaglandins Asthma/COPD Prior Authorization Criteria Updates Ophthalmic Prostaglandins Advair Diskus and Advair HFA TNF Alpha inhibitors Hepatitis C Proton Pump Inhibitors Policies/Forms Approved New: Pharm-12 Enteral Nutrition Products Revised: Pharm-01 Pharmacy and Therapeutics Committee
2 Approved Changes: Hepatitis C Drug Class Boceprevir (Victrelis ) 200 mg Ribapak mg tab, mg tab Ribavirin 400 mg tab 600 mg tab Simeprevir (Olysio ) 150 mg PA required PA required Sofosbuvir (Sovaldi ) 400 mg PA required PA required Telaprevir (Incivek ) 375 mg PA required PA required Ophthalmic Prostaglandins Drug Class Bimatoprost (Lumigan ) Latanoprost (Xalatan ) Travoprost (Travatan Z ) 21 y/o 21 y/o
3 Asthma/COPD Travoprost (Travatan ) ST with latanoprost; 21 y/o ST with latanoprost; 21 y/o Indacaterol (Arcapta Neohaler) Mometasone (Asmanex) Aclidinium (Tudorza Pressair) Ciclesonide (Alvesco) Budesonide/Formoterol (Symbicort) Fluticasone/Salmeterol (Advair Diskus Advair HFA) Mometasone/Formoterol (Dulera) Roflumilast (Daliresp) QL of #2 per 30 QL of #1 per 30 QL of 10.2 per 30 Non for 12 y/o; for 4-11 y/o QL of 13 per 30 QL of #2 per 30 QL of #1 per 30 QL of 10.2 per 30 Non for 12 y/o; for 4-11 y/o QL of 13 per 30
4 Proposed Changes Drug Name Medi-Cal Healthy Kids CWRAP Lorazepam QL #3 per day QL #3 per day No changes 0.5, 1, 2 mg Glycerin Excluded (OTC) suppositories Salicylic acid 17% liquid QL #15 per 30 Excluded (OTC) QL #15 per 30 Salicylic acid /Flex Collodion Liquid QL #14.8 per 30 Excluded (OTC) QL #14.8 per 30 Vitamin B-12 (Cyanocobalamin) 1,000 mcg IR Capscaicin 0.1% cream Estradiol Valerate 20mg/Ml, 10mg/Ml, 40mg/Ml Alprazolam ER ODT, 1 mg/ml solution Metformin ER 750 mg (Glucophage XR) Armour Thyroid 15mg 30mg Excluded (OTC) #42.5 grams per 30 Excluded (OTC) #42.5 grams per 30 #10 per 80 #10 per 80 No changes Excluded #2 per day #2 per day No changes, min age 21 y/o, min age 21 y/o No changes
5 60mg 90mg 120mg 180mg 240mg 300mg ASA/APAP/Caffeine mg (Excedrin) APAP/Caffeine mg (Excedrin) Isometheptene/ Dichloralphenazone/ Acetaminophen (Midrin) Isometheptene/ Caffeine/ Acetaminophen (Prodrin) Desmopressin 0.1, 0.2 mg tabs Bupropion SR 150 mg (Zyban) Bupropion XL 450 mg (Forfivo XL) Dexlansoprazole 30 mg, 60 mg (Dexilant ) Excluded (OTC) Excluded (OTC) Excluded Excluded 0.1 mg #1 per day 0.1 mg #1 per day No changes 0.2 mg #3 per day, age mg #3 per day, age 7-18 Esomeprazole Magnesium Step therapy QL #2/day Excluded (OTC) Step therapy QL
6 (Nexium 24HR-OTC) Esomeprazole (Nexium ) 20 mg, 40 mg Terbinafine 250 mg tabs (Lamisil) Fish oil 1000 mg caps, 1000 mg softgel caps Levofloxacin 250, 500, 750 mg Anakinra (Kineret ) Abatacept (Orencia ) Ustekinumab (Stelara ) Tofacitinib Citrate (Xeljanz ) *changes effective 8/15/14 CWRAP = Medicare/Medi-Cal (pantoprazole AND omeprazole) #2/day (pantoprazole AND omeprazole) No changes without without grandfathering grandfathering #90 per 365 #90 per 365 No changes #120 per 30 Excluded (OTC) #120 per 30 #30 per 30 #30 per 30 No changes
Pharmacy Updates Summary
All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 4/16/2014 Effective date: 5/15/2014 Therapeutic Classes reviewed: ADHD Ophthalmic antihistamines
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Pharmacy Updates Summary
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2018 PDP Premier Step Therapy Document September 2018 Y0114_18_33144_I_009
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