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 Gout Triptans Prior Authorization Criteria Updates ADHD Ophthalmic antihistamines Gout Triptans Sofosbuvir (Sovaldi ) Policies/Forms Approved None
Approved Changes: Attention Deficit Disorder Drug Class Amphetamine Salts 5, 7.5, 10, 12.5, 20, 30 mg tablets (Adderall )* Dexmethylphenidate Hydrochloride 2.5, 5, 10 mg tablets (Focalin )* Dextroamphetamine 2.5, 5, 7.5, 10 mg tablets (Zenzedi )* 5 and 10 mg: for 5 mg, 4 per day for 10 mg 5 and 10 mg: for 5 mg, 4 per day for 10 mg Dextroamphetamine IR 5 mg/5 ml solution (ProCentra )* 2.5 and 7.5 mg: no changes 2.5 and 7.5 mg: no changes
Dextroamphetamine sustained release 5, 10, 15 mg capsules (Dexedrine )* Prior Authorization required with Lisdexamfetamine Dimesylate 20, 30, 40, 50, 60, 70 mg capsules (Vyvanse )** 5, 10, 20 mg tablets (Ritalin )* Methylphenidate HCL 5 mg/5 ml, 10 mg/5 ml solution (Methylin)* 2.5, 5, 10 mg chewable tablets (Methylin ) Methylphenidate SR 20 mg tablet (Ritalin SR)* Methylphenidate ER 10, 20 mg tablet (Metadate ER ) and maximum age of 18 y/o Maximum daily dose 3 per day and maximum age of 12 y/o with Maximum daily dose 30 ml for 10 mg/5ml and 10 ml for 5 mg/5ml Prior Authorization required with and maximum age of 18 y/o Maximum daily dose 3 per day and maximum age of 12 y/o with Maximum daily dose 30 ml for 10 mg/5ml and 10 ml for 5 mg/5ml Age limit of minimum age 5 y/o and maximum 18 y/o, Maximum daily dose 2 per day for 10 mg and 3 per day for 20 mg Age limit of minimum age 5 y/o and maximum 18 y/o, Maximum daily dose 2 per day for 10 mg and 3 per day for 20 mg
ER 18, 27, 36, 54 mg osmotic release tablets (Concerta )* LA 10, 20, 30, 40 mg capsules (Ritalin LA )* CD 10, 20, 30, 40, 50, 60 mg capsules (Metadate CD )* Methylphenidate 10mg/9 hrs, 15mg/9 hrs, 20mg/9 hrs, 30mg/9 hrs patches (Daytrana ) Ophthalmic antihistamines Azelastine Step therapy with ketotifen, Step therapy with ketotifen, No changes (Optivar 0.05%) Max #6 ml per Max #6 ml per Epinastine* Step therapy with ketotifen, Step therapy with ketotifen, No changes (Elestat 0.05%) Max #5 ml per Max #5 ml per Olopatadine (Pataday 0.2%, Patanol 0.1%) Non- Non- No changes Gout
Drug Name Medi-Cal Healthy Kids Colchicine (Colcrys ) #30 per 3 fills per year #30 per 3 fills per year No changes Triptans Drug Name Medi-Cal Healthy Kids Sumatriptan Subcutaneous Injection Rizatriptan regular release (Maxalt) 5 mg 10 mg No Changes Rizatriptan ODT (Maxalt ODT) 5 mg 10 mg No Changes Naratriptan
(Amerge) Almotriptan (Axert) Frovatriptan (Frova) Eletriptan (Relpax) Zolmitriptan tablet (Zomig) Zolmitriptan nasal spray (Zomig) Zolmitriptan ODT (Zomig-ZMT) Proposed Changes Drug Name Medi-Cal Healthy Kids Albuterol 2, 4 mg tabs, QL #120 per, QL #120 per No Changes Nifedipine ER 24H 60 mg, QL #60 per, QL #60 per No Changes Azithromycin 250 mg, QL #30 per, QL #30 per No Changes Indomethacin 75 mg ER** Pioglitazone 15, 30, 45 mg, QL #1 per, QL #1 per No Changes day day Mycophenolate Mofetil 500,, No Changes
Mg Tablet Triamcinolone nasal spray (Nasacort OTC) *changes effective 5/15/2014 #6 per day, >21 y/o, QL #16.9 ml per #6 per day, >21 y/o Excluded, QL #16.9 ml per ST: Step Therapy : Medi-Medi