PHARMACY TIMES BY IEHP PHARMACEUTICAL SERVICES DEPARTMENT September 23, 2013 We would like to inform you of the following changes to the 2013 IEHP Formulary that were approved by the Pharmacy and Therapeutics Subcommittee in September 2013: IEHP FORMULARY ADDITIONS/DELETIONS Drug Name Classification Medi-Cal/HF/HK DualChoice Formulary Clomipramine Antidepressant Non-formulary Formulary Albuterol tablet Asthma Non-formulary Formulary Simethicone 80 mg chew Antiflatulent Formulary Non-formulary Auvi-Q (epinephrine) Anaphylaxis Formulary Formulary Liptruzet Hyperlipidemia Non-formulary; PA Non-formulary (ezetimibe/atorvastatin) Procysbi (cysteamine Metabolic agent Non-formulary; PA Non-formulary bitartrate) Kcentra (prothrombin complex Anticoagulation Non-formulary; PA conc. Human) reversal agent Xofigo (radium Ra 223 dichloride) Oncology Non-formulary; PA Formulary; PA (new Nymalize (nimodipine) Hemorrhage Non-formulary; PA Non-formulary Breo Ellipta COPD Non-formulary; PA Non-formulary (fluticasone/vilanterol) Tafinlar (dabrafenib) Oncology Non-formulary; PA Formulary; PA (new Mekinist (trametinib) Oncology Non-formulary; PA Non-formulary; PA (new Rixubis (factor IX) Hemophilia Non-formulary; PA Non-formulary Brisdelle (paroxetine) Menopause Non-formulary; PA Non-formulary Khedezla (desvenlafaxine) Antidepressant Non-formulary; PA Non-formulary; PA Gilotrif (afatinib) Oncology Non-formulary; PA Formulary; PA (new Zubsolv (buprenorphine/naloxone) Opioid dependence DHCS Carve Out HF/HK: Nonformulary; PA Non-formulary
Fetzima (levomilnacipran) Antidepressant Non-formulary; PA Formulary; PA (new Astagraf XL (tacrolimus) Transplant Non-formulary; PA Formulary; PA (new Xgeva (denosumab) Oncology Non-formulary; PA Formulary; PA (new Please Note: Generics are covered when available. Non-formulary agents may be requested through the Pharmacy Exception Request (PER) process Bolded Items: formulary status change as of Sep 2013 P&T IEHP PRIOR AUTHORIZATION UPDATES Drug Name Classification Medi-Cal/HF/HK DualChoice Formulary Glaucoma Agents Glaucoma See Class Monograph Erythropoiesisstimulating Agents (ESAs) Erythropoiesisstimulating Agents See Class Monograph Adult Nutritional Supplement Brand Name Drug Requests Nutritional See Class Monograph Supplements -- See Drug Policy Glycerol Phenylbutyrate (Ravicti) Cambia (diclofenac potassium for oral solution) Flector (diclofenac patch) Hyperammonemia Agent Migraine Pain See Drug Monograph Diagnosis of migraine AND failure or formulary NSAIDs (e.g ibuprofen, naproxen, diclofenac) and triptans (e.g. sumatriptan, rizatriptan) Diagnosis of pain due to strain, sprain, or contusion AND failure or formulary NSAIDs (e.g. ibuprofen, naproxen, diclofenac) Sprix (ketorolac NS) Pain Diagnosis of moderate to moderately-severe pain AND failure or oral formulation. If approved, restricted to 5-day supply for each episode. Pataday (olopatadine) Ophthalmic agent Failure or contraindication to formulary alternatives
(e.g. Alaway, Zaditor, Crolom, Naphcon-A) OR prescribed by optometrist or ophthalmologist Provigil (modafinil) Narcolepsy Diagnosis of narcolepsy with sleep study and failure or formulary stimulants OR Diagnosis of obstructive sleep apnea with sleep study and failure or using continuous positive airway pressure (CPAP) /oral appliance. Liptruzet (ezetimibe/ atorvastatin) Hyperlipidemia Failed or contraindicated to two formulary statins (e.g. simvastatin, pravastatin, lovastatin, atorvastatin). Lipid panel is required to determine failure. Procysbi (cysteamine bitartrate) Metabolic agent Kcentra (prothrombin Anticoagulation complex conc. Human) reversal agent Xofigo (radium Ra 223 Oncology dichloride) Nymalize (nimodipine) Hemorrhage Breo Ellipta COPD See Inhaled Corticosteroids (fluticasone/vilanterol) Class Monograph Tafinlar (dabrafenib) Oncology with confirmation of BRAF V600E mutations prior to starting therapy using a FDAapproved test and prescribed by Mekinist (trametinib) Oncology with confirmation of BRAF V600E or V600K mutations prior to starting therapy using a FDA-approved test and Failure of formulary statin Failure of formulary inhaled corticosteroids, steroid and LABA combination, and anticholinergic agents with confirmation of BRAF V600E mutations prior to starting therapy using a FDA-approved test and prescribed by with confirmation of BRAF V600E or V600K mutations prior to starting therapy using a FDA-approved test
prescribed by Rixubis (factor IX) Hemophilia Brisdelle (paroxetine) Menopause Failure of formulary hormone replacement or hormonal treatment Khedezla Antidepressant Diagnosis of depression AND (desvenlafaxine) Failure or contraindication to venlafaxine and one medication (6 week-trial each) from the following: formulary selective serotonin reuptake inhibitor (SSRI), mirtazapine, bupropion Gilotrif (afatinib) Oncology Zubsolv (buprenorphine/ naloxone) Fetzima (levomilnacipran) Opioid dependence Antidepressant Medi-Cal: DHCS Carve out HF/HK: Restricted to FDA approved and under the care of a dependence specialist Diagnosis of depression AND Failure or contraindication to venlafaxine and one medication (6 week-trial each) from the following: formulary selective serotonin reuptake inhibitor (SSRI), mirtazapine, bupropion Astagraf XL (tacrolimus) Transplant Sustiva (efavirenz) HIV Medi-Cal: DHCS Carve out HF/HK: FDA approved indication Tarceva (erlotinib) Oncology with confirmed EGFR mutation Simponi (golimumab) Ulcerative colitis Diagnosis of ulcerative colitis in adults who have demonstrated corticosteroid dependence or who failed aminosalicylates, oral corticosteroids, and prescribed by Failure of formulary hormone replacement or hormonal treatment Failure of formulary antidepressant (SSRI and venlafaxine) and under the care of a dependence specialist Failure of formulary antidepressant (SSRI and venlafaxine) with confirmed EGFR mutation Refer to Tumor Necrosis Factor (TNF) / Janus Kinase (JAK) Inhibitor drug class monograph
Ilaris (canakinumab) Juvenile Idiopathic Arthritis azathioprine, or mercaptopurine. If criteria are met, use Humira first. Refer to Tumor Necrosis Factor (TNF) / Janus Kinase (JAK) Inhibitor Class Monograph Revlimid (lenalidomide) Oncology Xgeva (denosumab) Giant cell tumor of bone Mycamine (micafungin) Candidemia prophylaxis Exelon patch Alzheimer s (rivastigmine) with trial and failure of formulary alternative(s) Latuda (lurasidone) Antidepressant Medi-Cal: DHCS Carve out HF/HK: FDA approved indication and failure of formulary alternatives. Vibativ (telavancin) Antibiotic FDA approved indicationvancomycin may be considered Full Prior Authorization table available at: http://ww2.iehp.org/iehp/providers/pharmaceutical+services/padrugcriterias_guides.htm with trial and failure of formulary alternatives for Alzheimer s and failure of formulary alternatives CLINICAL PRACTICE GUIDELINE UPDATE Clinical Practice Guideline Therapeutic Class Comment Diabetes Table Diabetes, Adult Update Hepatitis C- Genotype 1 Hepatitis Update IMPORTANT INFORMATION ABOUT IEHP CLINICAL PRACTICE GUIDELINES IEHP publishes and distributes an IEHP Formulary Book to our Providers every year. The IEHP Formulary Book contains IEHP treatment guidelines for drug therapy of various medical conditions and policies regarding the use of specific drugs. These recommendations (listed below), which have been approved by the Pharmacy and Therapeutics Subcommittee and Quality Management Committee, are based on published consensus guidelines and reviews of the medical literature. They do not favor any particular drug based solely on cost considerations. All therapy guidelines are current as of the time of printing and are subject to change. The Clinical Practice Guidelines are reviewed at least once every two years, or when a new update is available prior to the two-year schedule. When a new Clinical Practice Guideline is
available, IEHP communicates the changes to the provider via this quarterly Formulary Change notice. The guidelines are general and may not cover all clinical situations; they should not be considered in any way as a substitute for sound clinical judgment. IEHP Clinical Practice Guidelines currently available: Attention Deficit Hyperactivity Disorder Guideline and Toolkit Anti-Infective Therapy Guide Adult and Pediatric Asthma Care Quick Reference Chronic Kidney Disease Depression Diabetes Mellitus and Adolescent Toolkit Diabetes Pregnancy Fibromyalgia Gastroesophageal Reflux Disease Hepatitis C Hyperlipidemia Hypertension IVIG Migraine Multiple Sclerosis Osteoarthritis Pulmonary Arterial Hypertension Pain Management and Pain Quick Reference Guide Rheumatoid Arthritis Respiratory Syncytial Virus Sexually Transmitted Diseases - Summary of CDC Treatment Guidelines Smoking Cessation Synagis Criteria Season 2012/2013 We welcome any recommendations and comments regarding the IEHP Formulary. For questions, suggestions, or if you would like a printed copy of the IEHP Formulary Book or Clinical Practice Guideline, please call us at (909) 890-2067. As a reminder, updated formulary information and Clinical Practice Guidelines are available at www.iehp.org. Sincerely, IEHP Pharmaceutical Services