All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 10/28/2014 Effective date: 11/15/2014 Therapeutic Classes reviewed: Pulmonary arterial hypertension (PAH) Topical corticosteroids Topical calcineurin inhibitors Clostridium difficile agents Anti-malarial agents Prior Authorization Criteria Updates Pulmonary arterial hypertension (PAH) Topical corticosteroids Topical calcineurin inhibitors Anti-malarial agents Clostridium dificile agents Policies/Forms Approved None
Approved Changes: Pulmonary Arterial Hypertension (PAH) Drug Class Sildenafil Citrate (Revatio ) Sildenafil Citrate (Revatio ) Tadalafil (Adcirca ) 20mg tab PA Required PA Required Excluded 10mg/mL sol Non-formulary Non-formulary Excluded 20mg tab Non-formulary Non-formulary Excluded Ambrisentan (Letairis ) Bosentan (Tracleer ) 5mg tab 10mg tab 62.5mg tab 125mg tab PA Required PA Required Excluded Non-formulary Non-formulary Excluded Macitentan (Opsumit ) Riociguat (Adempas ) 10mg tab Non-formulary Non-formulary Excluded 0.5mg tab 1mg tab 1.5mg tab Prior Authorization Prior Authorization Excluded
Treprostinil Inhalation Solution (Tyvaso ) Treprostinil Inhalation Starter Kit (Tyvaso ) Iloprost (Ventavis ) Inhlation Solution 1.74mg/2.9mL 1.74mg/2.9mL 10mcg/mL 20mcg/mL Prior Authorization Prior Authorization Prior Authorization Prior Authorization Excluded Excluded Non-formulary Non-formulary Excluded Topical Corticosteroids Drug Class Ultra High Potency (Group 1): Clobetasol propionate 0.05% cream, emollient Fluocinonide 0.1% cream (Vanos ) Betamethasone dipropionate, augmented 0.05% Non-formulary Non-formulary Non-formulary Non-formulary
ointment Betamethasone dipropionate, augmented 0.05% lotion Betamethasone dipropionate, augmented 0.05% gel Clobetasol propionate 0.05% cream Clobetasol propionate 0.05% gel Clobetasol propionate 0.05% ointment Clobetasol 0.05% scalp solution Halobetasol propionate 0.05% ointment High Potency (Group 2):
Betamethasone dipropionate, augmented 0.05% cream (Diprolen AF) Desoximetasone 0.25% cream (Topicort ) #120 per 30 #120 per 30 High Potency (Group 3): Betamethasone valerate 0.1% ointment (Valisone) Fluocinonide E (emollient) 0.05% cream (Lidex) Mometasone furoate 0.1% ointment (Elocon) Betamethasone dipropionate 0.05% cream (Diprosone) Fluocinonide 0.05% cream (Dermacin)
Medium Potency (Group 4): Fluocinolone acetonide 0.025% ointment (Synalar) Mometasone furoate 0.1% cream (Elocon) Lower to Mid Potency (Group 5): Fluticasone propionate 0.05% cream (Cutivate) Hydrocortisone butyrate 0.1% ointment (Locoid) Desonide 0.1% ointment (DesOwen) Non-formulary Non-formulary Low Potency (Group 6):
Desonide 0.05% cream, lotion (Desonate ) Fluocinolone acetonide 0.01% cream (Synalar) Fluocinolone acetonide 0.01% solution (Synalar) Fluocinolone acetonide 0.01% Oil (scalp) (Derma- Smoothe/FS) Fluocinolone acetonide 0.01% Oil (body) (Derma- Smoothe/FS) Least Potent (Group 7): Hydrocortisone (base) 2.5% lotion (Hytone) #240 per 30 with selfgrandfathering #240 per 30 with selfgrandfathering No chnages
Hydrocortisone (base) 1.0% lotion (Aquinil HC, Sarnol HC, Cortizone-10) Hydrocortisone (base) 1% cream with aloe #240 per 30 with selfgrandfathering #240 per 30 with selfgrandfathering #240 per 30 with selfgrandfathering Excluded #240 per 30 with selfgrandfathering Topical Steroids Drug Class Tacrolimus (Protopic) 0.03%, 0.1% ointment Pimecrolimus (Elidel) 1% cream, ST with 2 medium to high potency corticosteroids, 2 y/o, QL 30 per 30, ST with 2 medium to high potency corticosteroids, 2 y/o, QL 30 per 30, ST with 2 medium to high potency corticosteroids, 2 y/o, QL 30 per 30, ST with 2 medium to high potency corticosteroids, 2 y/o, QL 30 per 30
Antimalarial Drug Class Quinidine Gluconate 324 mg tablets Daraprim (Pyrimethamine) 25 mg Qualaquin (Quinine Sulfate) 324 mg Non formulary Non formulary Non formulary Non formulary Non formulary Non formulary Clostridium Difficile Drug Class Vancomycin capsules (Vancocin ) Fidaxomicin (Dificid ), ST with metronidazole QL #40 per 10, 2 fills per year, ST with metronidazole QL #40 per 10, 2 fills per year Prior Authorization Prior Authorization
Proposed Changes Additions Docosanol (Abreva) #2 gm per 30 #2 gm per 30 #2 gm per 30 Nifedipine 10 mg IR Drysol QL #4 per day QL #35 per 30 QL #4 per day QL #35 per 30 Sotalol 80, 120 mg tablet 80 mg: #120 per 30, min 21 y/o 80 mg: #120 per 30, min 21 y/o Ipratropium nasal spray 0.06% (42 mcg), 120 mg: #60 per 30, min 21 y/o #15 per 30 120 mg: #60 per 30, min 21 y/o #15 per 30 Ipratropium nasal spray #30 per 30 0.03% (21 mcg) Levetiracetam ER 500, #30 per 30 750 mg tablet Urea 20% cream #85 per 30 Benzoyl peroxide 2% gel Benzoyl peroxide 10% gel #30 per 30 #30 per 30 Excluded (OTC) #85 per 30 Excluded (OTC) Excluded (OTC)
Nasalcrom / Cromolyn Nasal Spray Salonpas (methyl salicylate/menth/camph) Albenza 200mg Min Age 2yo Min Age > 18yo, QL #40 per 30 QL#4/fill and max 2 fills/yr Excluded (OTC) Min Age 2yo Excluded, Min Age >18 yo, QL #40 per 30 QL#4/fill and max 2 fills/yr Gender Edit Added Bicalutamide 50mg (Casodex) Gender limit: Male Gender limit: Male Age Edits Removed Phenytoin 50 mg chewable tablets (Dilantin) QL# 180 per 30 QL# 180 per 30
Quantity Limits Added Tretinoin all strengths and formulations (topical) < 30 y/o QL of 15 gm for gel 0.01%, 0.025% QL of 20 gm for cream 0.025%, 0.05%, 0.1%; gel 0.1% < 30 y/o QL of 15 gm for gel 0.01%, 0.025% QL of 20 gm for cream 0.025%, 0.05%, 0.1%; gel 0.1% Step Therapy Removed Carisoprodol 350 mg (Soma) QL #120 per 30 QL #120 per 30 Quantity Limits Increased Triamcinolone Acetonide 0.1 % Cream #454 per 30 #454 per 30
Terazosin 5mg with QL#3/day with QL#3/day Mycophenolate 250mg with QL#6/day with QL#6/day Deletion ALTRETAMINE (HEXALEN) Non formulary Non formulary Aquaphor No Changes Excluded No Changes Atropine Sulfate; Non-formulary Non-formulary Hyoscyamine Sulfate; Phenobarbital; Scopolamine Hydrobromide (Donnatal ) elixir CAFFEINE; ERGOTAMINE Non formulary Non formulary TARTRATE (Cafergot tablets) CAFFEINE; ERGOTAMINE Non formulary Non formulary TARTRATE (Migergot suppositories) CHLORAMBUCIL (LEUKERAN) Non formulary Non formulary Dicyclomine Non-formulary Non-formulary
Hydrochloride10mg/5ml solution ERGOTAMINE TARTRATE Non-formulary Non-formulary 2MG SUBL (ERGOMAR) ESTRAMUSTINE PHOSPHATE SODIUM (EMCYT) Non formulary Non formulary ETOPOSIDE Non formulary Non formulary Hyoscyamine Non-formulary Non-formulary 0.125mg/5ml elixir Hyoscyamine Sulfate Non-formulary Non-formulary 0.125mg/5ml solution Intuniv ER (Guanfacine Non Non Excluded ER) 1mg, 2mg, 3 mg, 4 mg Isopropyl Alcohol 7% No Changes Excluded No Changes (alcohol preps) OXYCODONE (OXECTA) Non-formulary Non-formulary Piperonyl butoxide ; No Changes Excluded No Changes Pyrethrins 4%/0.33% (Lice Treatment Rinse) Piperonyl Excluded No Changes Butoxide;Pyrethrins 4%/0.33% (Lice Killing Shampoo) PROCARBAZINE Non formulary Non formulary HYDROCHLORIDE (MATULANE) Psyllium 520mg (Konsyl) No Changes Excluded No Changes TEMOZOLOMIDE 5, 20, Non formulary Non formulary
100, 250 THIOGUANINE (TABLOID) Non formulary Non formulary Trazodone 300 mg Non formulary Non formulary ALBUTEROL SULFATE; Non-formulary Non-formulary IPRATROPIUM BROMIDE 103MCG/ACT; 18MCG/ACT (COMBIVENT) Eflornithine 13.9% Excluded Excluded Excluded CREAM (VANIQA) Finasteride 1 mg Excluded Excluded (Propecia) ALISKIREN FUMARATE Non-formulary Non-formulary (TEKTURNA) ALISKIREN FUMARATE; Non-formulary Non-formulary AMLODIPINE BESYLATE (TEKAMLO) ALISKIREN FUMARATE; Non-formulary Non-formulary AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE (AMTURNIDE) ALISKIREN FUMARATE; Non-formulary Non-formulary HYDROCHLOROTHIAZIDE (TEKTURNA HCT) AMLODIPINE BESYLATE; HYDROCHLOROTHIAZIDE; OLMESARTAN MEDOXOMIL Non-formulary Non-formulary
(TRIBENZOR) AMLODIPINE BESYLATE; Non-formulary Non-formulary HYDROCHLOROTHIAZIDE; VALSARTAN (EXFORGE HCT) AZILSARTAN (EDARBI) Non-formulary Non-formulary DESVENLAFAXINE Non-formulary Non-formulary SUCCINATE MONOHYDRATE (PRISTIQ) DICLOFENAC (ZIPSOR) Non-formulary Non-formulary DICLOFENAC POTASSIUM Non-formulary Non-formulary 50 mg POWDER PACK (CAMBIA) Doxycycline hyclate Non-formulary Non-formulary 20mg kit (Alodox convenience kit) EPROSARTAN MESYLATE; Non-formulary Non-formulary HYDROCHLOROTHIAZIDE (TEVETEN HCT) FENOPROFEN (NALFON) Non-formulary Non-formulary FENTANYL CITRATE Non-formulary Non-formulary SOLUTION (LAZANDA) FLUVASTATIN ER 80 MG Non-formulary Non-formulary (LESCOL XL) HYDROCHLOROTHIAZIDE; Non-formulary Non-formulary OLMESARTAN MEDOXOMIL (BENICAR HCT) HYDROXYPROGESTERON E CAPROATE (MAKENA) Excluded Excluded
LOVASTATIN ER Non-formulary Non-formulary (ALTOPREV) LOVASTATIN; NIACIN Non-formulary Non-formulary (ADVICOR) METFORMIN ; Non-formulary Non-formulary PIOGLITAZONE METFORMIN ER Non-formulary Non-formulary (GLUMETZA) METFORMIN; Non-formulary Non-formulary ROSIGLITAZONE (AVANDAMET) NAPROXEN 24 HR Non-formulary Non-formulary (NAPRELAN) NEBIVOLOL Non-formulary Non-formulary HYDROCHLORIDE (BYSTOLIC) NIACIN; SIMVASTATIN Non-formulary Non-formulary (SIMCOR) OLMESARTAN (BENICAR) Non-formulary Non-formulary OLOPATADINE Non-formulary Non-formulary HYDROCHLORIDE (PATANASE) PAROXETINE MESYLATE Non-formulary Non-formulary (PEXEVA) Peginterferon Alfa-2b Non-formulary Non-formulary (Peg-Intron) PITAVASTATIN (LIVALO) Non-formulary Non-formulary ROSIGLITAZONE Non-formulary Non-formulary (AVANDIA) TOCILIZUMAB (ACTEMRA) SC Non-formulary Non-formulary
VILAZODONE Non-formulary Non-formulary HYDROCHLORIDE (VIIBRYD) ZAFIRLUKAST Non-formulary Non-formulary (ACCOLATE) Atropine Sulfate; Non-formulary Non-formulary Excluded Hyoscyamine Sulfate; Phenobarbital; Scopolamine Hydrobromide (Donnatal ) tablets Hyoscyamine CR 0.375 Non-formulary Non-formulary mg tabs (Symax Duotab) Mesalamine enema kit (Rowasa) Non-formulary Non-formulary *changes effective 11/15/14 CWRAP = Medicare/Medi-Cal