PHOTOFRIN Porfimer ALL LOB: ADD NF PA FETZIMA Levomilnacipran 20-40mg Titration pack ALL LOB: Add NF with PA

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1 March 24, 2014 Subject: February 13, 2014 LA Care PT&T Updates Dear Practitioner: We would like to thank you for providing quality services to our LA Care Medi-Cal (LAC01), Healthy Kids (LAC02), Healthy Families (LAC04) and PASC-SEIU (LAC06) members. LA Care s Pharmacy, Therapeutics and New Technology (PT&T) Committee reviewed several drugs and Prior Authorization guidelines on February 13, The purpose of this notification is to inform you of the changes with adjudication effective date of March Please transition your members from non-formulary to the formulary alternatives if appropriate. Summary of Drugs Reviewed Brand Name Generic Name Strength Formulary/Edits ALL LOB: ADD QL: #60/30 25mg DAYS ALL LOB: ADD QL: #60/30 100mg DAYS ALL LOB: ADD QL: #90/30 150mg DAYS 20MG DAYS and PA 30MG DAYS and PA 40mg DAYS and PA PHOTOFRIN Porfimer ALL LOB: ADD NF PA 20-40mg Titration pack ALL LOB: Add NF with PA 20MG ALL LOB: Add NF with PA 40mg ALL LOB: Add NF with PA 80mg ALL LOB: Add NF with PA 120mg ALL LOB: Add NF with PA IMBRUVICA Ibrutinib 140 mg ALL LOB: Add F with PA SOLVALDI Sofosbuvir 400 mg ALL LOB: Add F with PA OLYSIO Simeprevir 150mg ALL LOB: Add NF INCIVEK Telaprevir 375 mg LAC 06: ADD F, PA VICTRELIS Boceprevir ALL LOB: Remove from F

2 FOCALIN XR Dexmethylphenidate 15MG FOCALIN XR Dexmethylphenidate 30MG FOCALIN XR Dexmethylphenidate 40MG Hydrocodone/acetaminophen 7.5/325 ALL LOB: Change to F, PA XYZAL Levocetirizine 2.5mg/5ml ALL LOB: F, Age <2 years CYMBALTA Duloxetine 20MG CYMBALTA Duloxetine 30MG CYMBALTA Duloxetine 60MG DETROL LA Tolterodine 2MG DETROL LA Tolterodine 4MG Posaconazole NOXAFIL 100MG ALL LOB: NF ZOMIG Zolmitriptan 2.5MG ALL LOB: F, ST (T/F oral triptans), QL (12 SPRAYS/30 DAYS) AVAR LS Sulfacetamide/sulfur 10%-2% ALL LOB: NF AVAR Sulfacetamide/sulfur 9.5 %-5% ALL LOB: NF AEROSPAN Flunisolide 80 mcg ALL LOB: NF VERSACLOZ Clozapine 50mg/ml LAC 01: Carved Out; LAC 02-06: NF METAGLIP Glipizide/metformin 2.5MG/250MG Add to Formulary METAGLIP Glipizide/metformin 2.5MG/500MG Add to Formulary TAMIFLU Oseltamivir 12MG/1ML Remove from Formulary TAMIFLU Oseltamivir 6MG/1ML Add to Formulary EXFORGE Amlodipine/valsartan 5/160mg EXFORGE Amlodipine/valsartan 5/320 mg EXFORGE Amlodipine/valsartan 10/160 mg EXFORGE Amlodipine/valsartan 10/320 mg AZOR Amlodipine/olmesartan 5/20 mg AZOR Amlodipine/olmesartan 5/40 mg

3 AZOR Amlodipine/olmesartan 10/20 mg AZOR Amlodipine/olmesartan 10/40 mg CARNITOR Levocarnitine 330 mg Add to Formulary with PA required. CARNITOR Levocarnitine (otc) 250 mg LOB: Add to Formulary CARNITOR Levocarnitine (otc) 500 mg LOB: Add to Formulary RETROVIR Zidovudine 300 mg RETROVIR Zidovudine 100 mg RETROVIR Zidovudine 50mg/ 5 ml VIDEX Didanosine 125 mg VIDEX Didanosine 200 mg VIDEX Didanosine 250 mg VIDEX Didanosine 400 mg VIDEX Didanosine 2 GM QL UP TO 100 DAYS SUPPLY. 01) : Add to Formulary: Remove PA, UP TO 100 DAYS SUPPLY.

4 VIDEX Didanosine 4 GM 01) : Add to Formulary: Remove PA, UP TO 100 DAYS SUPPLY. Summary of Guideline Reviews from February 13, 2014 P&T Termed/Discontinued New Updated/Changed Notes/Comments Buprenorphine Agents Dalfampridine (Ampyra) Diclofenac Gel (Voltaren) Add buprenorphine (Butran) to guideline for pain Remove requirement for documentation of at least 15% improvement. Add the trial and failure of two legend NSAID for at least 2 weeks each. HIV Agents LAC01 and LAC02-Retire PA GL, add QL and Days supply. Hydroxyprogesterone (Makena) Lanthanum (Fosrenol) Lidodaine Patch (Lidoderm) Niacin (Niaspan) Remove the step requirement for compounded agent. Include recommendations from nephrologists. Renagel and Renvela are equal status. Add dosing of gabapentin of up to 1800mg/day for 4 weeks. Need to try and generic legend niacin. Non-formulary Drugs Sevelamer Renagel/Renvela are

5 (Renagel/Renvela) equal formulary status. ARB/CCB Combo Celecoxib (Celebrex) Non-formulary ARBs Thiazolidinediones to metformin. Hydromorphone ER (Exalgo) ER (Fetzima) Sofosbuvir (Solvadi) If you believe that your patients need to be on non-formulary medications or require an exception for Quantity Limitations or Step Therapy requirements, please do one of the following: 1. Fax a completed Medication Request Form to MedImpact at , OR 2. Contact MedImpact at (800) and provide all necessary information requested and followed with a signed MRF within one business day. This information is being provided for general information purposes only and is not intended as a substitute for the independent medical judgment of a practitioner. Only the treating practitioner can determine what medications are appropriate for their patient(s). Electronic version of LA Care s Formulary and other Formulary Updates are always available online at Thank you again for working with LA Care to provide our members with quality healthcare. L.A. Care Health Plan Pharmacy and Formulary Department

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