Provider Alerts

Effective 12/16/2016, the Pharmacy and Therapeutics Committee has approved the following changes:

Additions to the Formulary:

1. Xigduo XR (Dapagliflozin/Metformin) 5mg-500mg, 5mg-1000mg, 10mg-500mg, 10mg- 1000mg:
   1. Step therapy to patients who have tried and failed Invokana or Jardiance
   2. Xigduo XR 10mg-500mg, 10mg-1000mg are limited to 1 tablet/day
   3. Xigduo XR 5mg-500mg, 5mg-1000mg are limited to 2 tablets/day
2. Jentadueto XR (Linagliptin/Metformin) 2.5mg-1000mg, 5mg-1000mg:
   1. Jentadueto XR 5mg-1000mg is limited to 1 tablet/day
   2. Jentadueto XR 2.5mg-1000mg is limited to 2 tablets/day
3. Sofosbuvir/Velpatasvir (Epclusa): PA required. This medication is restricted to Diplomat Specialty Pharmacy. Please see the Hepatitis C Coverage Policy for preferred regimens.
4. Dasabuvir/Ombitasvir/Paritaprevir/Ritonavir (Viekira XR): PA required. This medication is restricted to Diplomat Specialty Pharmacy. Please see the Hepatitis C Coverage Policy for preferred regimens.
5. Doxycycline Monohydrate 100 mg Tablets: No PA required.
6. Epinephrine Auto-Injector Pens (Generic): No PA required. Manufactured by Lineage Therapy and A-S Medication.

Formulary Status Changes:

1. Entresto (Sacubitril/Valsartan):
   1. Restricted to members with ejection fraction less than 35%
   2. ECHO results performed within the past 3 months and results provided
   3. Members must have tolerated maximal doses of ACE-I or ARB (Members who do not tolerate one ACE-I/ARB must try another d. Reserved as add-on therapy to the following drugs at maximized doses (unless contraindicated):
      1. Beta-blocker (Metoprolol, Carvedilol, or Bisoprolol)
      2. Aldosterone Antagonists
2. Onglyza (Saxagliptin) 2.5 mg, 5mg; Kombiglyze XR (Saxagliptin/Metformin) 5mg-500mg, 5mg-1000mg, 2.5mg-1000mg: PA required. Reserved for an inadequate response to an adequate and concurrent trial of metformin, unless intolerant or contraindicated, AND for patients who have tried and failed Januvia and Tradjenta. A documented trial of Metformin ER is required if metformin cannot be tolerated due to GI side effects.
   1. Onglyza 2.5 mg is only to be used when renal function declines below 50 mL/min
   2. Standard dosing is Onglyza 5 mg daily
3. Kombiglyze XR (Saxagliptin/Metformin) 5mg-500mg, 5mg-1000mg, 2.5mg-1000mg: PA required. Reserved for patients who have tried and failed Januvia and Tradjenta.
   1. Kombiglyze XR 5mg-500mg and Kombiglyze 5mg-1000mg are limited to 1 tablet/day
   2. Kombiglyze XR 2.5mg-1000mg is limited to 2 tablets/day Page 2 of 2 Formulary Update October 12, 2016
4. Codeine-containing products: Must be greater than or equal to 12 years of age for any of the following products: a.
   1. Promethazine/Codeine
   2. Guaifenesin/Codeine
   3. Promethazine/Phenylephrine/Codeine
   4. Pseudoephedrine/Codeine/Chlorpheniramine
   5. Pseudoephedrine/Codeine/Guaifenesin
5. Promethazine-containing products: Must be greater than or equal to 2 years of age. For children between ages 2 and 6, they are limited to 1 fill per 365 days for any of the following products:
   1. Promethazine
   2. Promethazine DM
   3. Promethazine/Phenylephrine

Deletions from the Formulary:

The following products will be removed from the formulary as of December 16, 2016:

Health Plan of San Joaquin is dedicated to providing all members the best health care available in the most effective and efficient manner. We believe that this change in our Pharmacy Drug Benefit will not affect the quality of the care you provide.

You may contact our Provider Services Department with any questions or concerns Monday through Friday 8:00 am to 5:00 pm at (209) 942-6340 or 1-888-936-PLAN (7526).
Thank you for your continued support of Health Plan of San Joaquin.