All of the following changes were reviewed and approved by the SFHP Pharmacy & Therapeutics (P&T) Committee on 04/15/2015 Effective date: 05/15/2015 Therapeutic Classes reviewed: Testosterone replacement therapy Topical Antivirals Oral Fluoroquinolones Cystic Fibrosis Hepatitis B Hepatitis C Linezolid (Zyvox) Prior Authorization Criteria Updates Testosterone replacement therapy (new) Topical Antivirals Oral Fluoroquinolones (new) Cystic Fibrosis Hepatitis B Hepatitis C Topical calcineurin inhibitors Long acting opiates Makena (new) Policies/Forms Approved None
Approved Formulary Changes From Drug Class Review: Testosterone Replace Therapy Medication (GCN) Generic Utilization Topical products Health Kids Androderm 4 mg/ 24 hour transdermal patch (29171) Androgel 25 mg (1%) gel packet* (47851) Androgel 50 mg (1%) gel packet* (47852) Androgel 1% metered dose gel pump* (23141) Androgel 1.25 g (1.62%) gel packet (33452) Androgel 2.5 g (1.62%) gel packet (33453) Androgel 1.62% metered dose gel pump (29905) Axiron 30 mg/1.5 ml solution metered dose pump (29647) No 5 claims 4 members Yes -- Yes 29 claims Nonformularformularformulary 14 members Yes -- No -- No No No 2 claims 1 member 13 claims 8 members 1 claim 1 member formulary formulary formulary formulary formulary formulary formulary formulary formulary formulary formulary formulary formulary formulary First testosterone 2% No -- #60g #60g
Delatestryl 200 mg/ml vial* (10253) Depo - Testosterone 100mg/ml vial* (10191) Testopel 75 mg pellet (02660) Yes Yes 7 claims 6 members 1 claim 1 member Medication (GCN) Generic Utilization Health Kids cream (18941) formulary formulary formulary per 30 per 30 #60g per 30 First testosterone 2% No -- Nonformularformularformulary #60g #60g ointment (89903) per 30 per 30 #60g per 30 Injectable products #5ml per 30 #10ml per 30 #5ml per 30 #10ml per 30 #5ml per 30 #10ml per 30 Topical Antivirals Drug Name/Strength/ Dosage Form/GCN Penciclovir (Denavir ) 1% cream (37051) Acyclovir (Zovirax ) 5% cream (62420) No -- formulary formulary formulary formulary formulary
Oral Fluoroquinolones Medication Noroxin 400 mg tablet (41920) Ciprofloxacin 500 mg ER tablet (18898) Ciprofloxacin 1000 mg ER tablet (20315) Levofloxacin 250 mg/10 ml (23725) Levofloxacin 500 mg/20 ml (35624) Healthy Kids formulary Formulary Formulary Formulary formulary Nonformularformulary formulary Nonformularformulary QL* QL* QL* Nonformularformularformulary Nonformularformulary = Medicare/
Drug Name/Strength/ Dosage Form Entecavir (Baraclude) 0.05 mg/ml oral solution Lamivudine (Epivir) 25 mg/5 ml oral solution Hepatitis B Agents GCN 24465 50911 = Medicare/ (dual eligibles) formulary formulary formulary formulary Drug Name/Strength/ Dosage Form Ledipasvir/Sofos buvir (Harvoni) 90mg-400 mg tablet Simeprevir (Olysio) 150 mg tablet Hepatitis C Agents GCN 35648 = Medicare/ (dual eligibles) 37179 PA required PA required formulary formulary
Linezolid Drug Name/Strength /Dosage Form/GCN Linezolid (Zyvox ) 600mg tablet (26870) Linezolid (Zyvox ) 100mg/5mL suspension (26781) formulary formulary formulary QL #56tablets/28, or 1,680mL/28, max 1 fill/year formulary formulary formulary QL #56tablets/28, or 1,680mL/28, max 1 fill/year = Medicare/ (dual eligibles) QL #56tablets/28, or 1,680mL/28, max 1 fill/year QL #56tablets/28, or 1,680mL/28, max 1 fill/year QL #56tablets/28, or 1,680mL/28, max 1 fill/year QL #56tablets/28, or 1,680mL/28, max 1 fill/year
Drug Name/Strengt h/dosage Form/GCN Tacrolimus 0.03%, 0.1% ointment (12289) Pimecrolimus 1% cream (Elidel) (15348) Amantadine 100 mg capsule (17520) Amantadine 50 mg/5 ml syrup (17530) Rosuvastatin 40mg (Crestor ) tablet (19155) Rosuvastatin 20mg (Crestor ) tablet (19154) Pharmacy Updates Summary Approved Formulary Changes: ST with 2 potency corticosteroids, 2 y/o, QL 30 per 30 ST with 2 potency corticosteroids, 2 y/o, QL 30 per 30 ST with 2 potency corticosteroids, 2 y/o, QL 30 per 30 ST with 2 potency corticosteroids, 2 y/o, QL 30 per 30 ST with 2 potency corticosteroids, 2 y/o, QL 30 per 30 ST with 1 potency corticosteroid, QL 30 per 30 ST with 1 medium to high potency corticosteroid, QL 30 per 30 ST with 1 medium to high potency corticosteroid, QL 30 per 30 formulary formulary formulary Formulary formulary formulary Formulary formulary formulary formulary ST QL#30/30 formulary ST QL#30/30 ST QL#30/30 ST QL#30/30 ST QL#30/30 ST QL#30/30 Rosuvastatin formulary ST ST ST
Drug Name/Strengt h/dosage Form/GCN 10mg (Crestor ) tablet (19153) Rosuvastatin 5mg (Crestor ) tablet (20229) Accu-Chek Aviva Plus test strips (25200) Accu-Chek SmartView test strips (25200) Alendronate sodium 70mg tablet (85361) Urea 40% cream (24774) Desmopressin acetate 0.2mg tablet (26172) QL#30/30 formulary ST QL#30/30 QL QL age restriction 50 yo minimum QL QL age restriction 50 yo minimum QL QL age restriction 50 yo minimum QL #4 strips/day for all others QL #4 strips/day for all others age restriction formulary formulary formulary Formulary QL #198.6gm/30 age restriction 7-18yo, QL#90/30 age restriction 7-18yo, QL#90/30 age restriction 7-18yo, QL#90/30 age restriction, QL#90/30 QL#30/30 ST QL#30/30 QL prenatal vitamins, #4strips/day for QL prenatal vitamins, #4 strips/day for all others age restriction Formulary QL #198.6gm/30 age restriction, QL#90/30 QL#30/30 ST QL#30/30 QL prenatal vitamins, #4strips/day for QL prenatal vitamins, #4 strips/day for all others age restriction Formulary QL #198.6gm/30 age restriction, QL#90/30
Drug Name/Strengt h/dosage Form/GCN Ofloxacin 0.3% otic solution (13880) Guanfacine 1mg tablet (32480) Guanfacine 2mg tablet (32481) Proventil HFA 90mcg/ actuation inhaler (22913) Nifedipine 10mg capsule (2350) Clarithromyci n 250mg tablet (48852) Clarithromyci n 500mg tablet (48851) Makena (11180) Pharmacy Updates Summary 1 fill/year 1 fill/year 1 fill/year yearly limit, QL#5mL/30 QL #30/30 QL #30/30 QL #30/30 QL #30/30 QL #30/30 QL #30/30 QL#45/30 QL#45/30 formulary formulary formulary ST w/ Ventolin and ProAir, QL #13.4grams/30 QL#120/30 QL #28/14 QL #28/14 QL#120/30 QL #28/14 QL #28/14 QL#120/30 QL #28/14 QL #28/14 QL#180/30 yearly limit, QL#5mL/30 QL#45/30 QL#45/30 ST w/ Ventolin and ProAir, QL#13.4grams/3 0 QL#180/30 QL#2/day QL#2/day QL #2/day QL#2/day yearly limit, QL#5mL/30 QL#45/30 QL#45/30 ST w/ Ventolin and ProAir, QL#13.4grams/30 QL#180/30 QL#2/day QL#2/day formulary formulary formulary *Generic available
= Medicare/ (dual eligibles) ST = step therapy Drug Name Approved Interim Formulary Changes: Latanoprost 0.005% solution Spiriva Respirmat Vitekta (elvitegravir) Evotaz (atazanavir sulfate/cobicistat) Prezcobix (darunavir/cobicistat) Formulary #2.5 per 30 Formulary #2.5 Formulary #2.5 Formulary Formulary Formulary per 30 per 30 (Rx) #2.5 per 25 #2.5 per 25 #2.5 per 25 formulary formulary Formulary Formulary #4 Formulary #4 per 30 per 30 (1 #4 per 30 (1 inhaler) (1 inhaler) inhaler) formulary formulary No changes = Medicare/ (dual eligibles) Effective Date 2/5/15 2/26/15 3/16/15