Provider Alerts

Effective October 4, 2022, the Pharmacy and Therapeutics Committee has approved the following changes to the medical benefit. All of the below criteria is specific to the HPSJ Psoriatic Arthritis Coverage Policy.

1. Code Q5104 – INJECTION, INFLIXIMAB-ABDA, BIOSIMILAR (RENFLEXIS), 10MG
   • • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
     • Must be prescribed by a rheumatologist or dermatologist.
2. Code Q5103 – INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR (INFLECTRA), 10MG
   • • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried
     • Must be prescribed by a rheumatologist or dermatologist.
3. Code J1602 – INJECTION, GOLIMUMAB (SIMPONI), 1 MG, FOR INTRAVENOUS USE
   • • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
     • Must be prescribed by a rheumatologist or dermatologist.
4. Code J0717 – INJECTION, CERTOLIZUMAB PEGOL (CIMZIA), 1MG
   • • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomid). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
     • Must be prescribed by a rheumatologist or dermatologist.
5. Code J3357 – USTEKINUMAB (STELARA), FOR SUBCUTANEOUS INJECTION, 1MG
   • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
   • Must be prescribed by a rheumatologist or dermatologist.
6. Temporary use of unclassified codes (J3590) – INJECTION, IXEKIZUMAB (TALTZ)
   • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
   • Must be prescribed by a rheumatologist or dermatologist.
7. Code J0129 – INJECTION, ABATACEPT (ORENCIA), 10MG
   • Reserved for treatment failure to 12 weeks of dose-optimized, oral DMARD therapy (Methotrexate 15-25mg/week, Cyclosporine, Sulfasalazine, and Leflunomide). If patient is unable to tolerate one oral DMARD, a second oral DMARD must be tried.
   • Must be prescribed by a rheumatologist or dermatologist.
8. Code J0135 – INJECTION, ADALIMUMAB (HUMIRA), 20MG
   • Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Simponi, Cimzia, Stelara, Taltz, or Orencia
   • Must be prescribed by a rheumatologist or dermatologist.
9. Code J1438 – INJECTION, ETANERCEPT (ENBREL), 25MG
   • Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Simponi, Cimzia, Stelara, Taltz, or Orencia.
   • Must be prescribed by a rheumatologist or dermatologist.
10. Temporary use of unclassified codes (J3590) – INJECTION, SECUKINUMAB (COSENTYX),
    • Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Simponi, Cimzia, Stelara, Taltz, or Orencia.
    • Must be prescribed by a rheumatologist or dermatologist.
11. Code J1628 – INJECTION, GUSELKUMAB (TREMFYA), 1MG
    • Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Simponi, Cimzia, Stelara, Taltz, or Orencia.
    • Must be prescribed by a rheumatologist or dermatologist
12. . Temporary use of unclassified codes (J3590) – INJECTION, RISANKIZUMAB (SKYRIZI)
    • Reserved for treatment failure/documented intolerance to Renflexis, Inflectra, Simponi, Cimzia, Stelara, Taltz, or Orencia.
    • Must be prescribed by a rheumatologist or dermatologist.

You may contact our Customer Service Department with any questions or concerns, Monday through Friday, 8:00 am to 5:00 pm, at 1-888-936-PLAN (7526), TDD/TYY 711. Thank you for your continued support of Health Plan of San Joaquin. You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/.