PHARMACY TIMES BY IEHP PHARMACEUTICAL SERVICES DEPARTMENT November 20, 2013

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1 PHARMACY TIMES BY IEHP PHARMACEUTICAL SERVICES DEPARTMENT November 20, 2013 We would like to inform you of the following changes to the 2013 IEHP that were approved by the Pharmacy and Therapeutics Subcommittee in November 2013: Drug Name Tivicay (Dolutegravir) Strength & Dosage Form 50mg Tab IEHP FORMULARY ADDITIONS/DELETIONS Classification Medi-Cal/HF/HK DualChoice HIV integrase strand transfer Inhibitor Medi-Cal: DHCS carve out Valchlor (Mechlorethamine) Menveo (Meningococcal Vaccine) Abraxane (Paclitaxel) Treanda (Bendamustine) Perjeta (Pertuzumab) 0.016% Top Gel Cell cycle-phase nonspecific antineoplastic agent 0.5 ml INJ Quadrivalent vaccine >2 months of age 100 mg Pwder INJ 25 mg 100 mg Pwder INJ 420mg/14mL HF/HK: Nonformulary Non-formulary In office; Medical benefit ; PA Microtubule inhibitor Non-formulary ; PA Antimetabolite and Non-formulary ; PA alkylator cytotoxic activity Humanized recombinant monoclonal antibody neoadjunct (before surgery) in high-risk HER2 positive early stage breast cancer Non-formulary ; PA Please Note: Generics are covered when available. Non-formulary agents may be requested through the Pharmacy Exception Request (PER) process Bolded Items: status change as of November 2013 P&T

2 IEHP PRIOR AUTHORIZATION UPDATES Drug Name Classification Medi-Cal/HF/HK DualChoice Abraxane(Paclitaxel) Microtubule inhibitor Adempas (Riociguat) Guanylate cyclase stimulator ; Must use DTM Vendor Alpha-1 proteinase inhibitor Blood modifier See class monograph agent Botox (Onabotulinum) Neurotoxin See drug monograph Botox Cosmetic (Onabotulinum) Neurotoxin Not a covered benefit (cosmetic); Indication of treatment of severe lateral canthal lines Cimzia (Certolizumab) TNF modifier For active psoriatic For ankylosing spondylitis must fail two NSAIDs, then fail Not a covered benefit (cosmetic); Indication of treatment of severe lateral canthal lines For active psoriatic For ankylosing spondylitis must fail two NSAIDs, then fail Duavee (Conjugated estrogen/ Bazedoxifene) Estrogen derivative Must fail formulary alternatives such as estrogen and progestin products Epaned (Enalapril) Anti-hypertensive Failure of formulary ACEI alternatives and must provide medical justification why solid oral formulation cannot be used Esomeprazole Strontium Exjade (Deferasirox) Proton Pump Inhibitor Heavy metal chelator Failure or contraindicated to formulary alternatives (Prilosec OTC, Protonix, and Prevacid OTC), then Dexilant See drug monograph Must fail formulary alternatives such as estrogen and progestin products Failure of formulary ACEI alternatives and must provide medical justification why solid oral formulation cannot be used Failure or contraindicated to formulary alternatives (Prilosec OTC, Protonix, and Prevacid OTC) then Dexilant All FDA approved

3 Lamisil (Terbinafine) Antifungal Limited to 3 months of treatment without prior authorization. Continuation beyond 3 months therapy requires clinical justification (e.g. zero nail growth, severe immunosuppression, and high dermatophyte resistance), liver function tests, and a timeout period of 12 weeks. Lucentis (Ranibizumab) Recombinant humanized monoclonal antibody See Macular Degeneration class monograph Lupron Depot (Leuprolide) GnRH agonist See drug monograph All FDA approved Menveo (Meningococcal Vaccine) Quadrivalent vaccine >2 months of age In Office; Medical Benefit Mirvaso (Brimonidine) Selective alpha-agonist Perjeta (Pertuzumab) Humanized Recombinant Monoclonal Antibody Neoadjunct (before surgery) in high-risk HER2 positive early stage breast cancer Sensipar (Cinacalcet) Calcimimetic, See drug monograph calcium regulator Stelara (Ustekinumab) Antipsoriatic agent For active psoriatic For active psoriatic Testosterone Hormone replacement See class monograph All FDA approved

4 Tivicay (Dolutegravir) HIV integrase strand transfer Inhibitor Medi-Cal: DHCS carve out Treanda (Bendamustine) Antimetabolite and alkylator cytotoxic activity HF/HK: Trokendi XR (Topiramate) Antiepileptic Use generic topiramate Valchlor (Mechlorethamine) Cell cycle-phase nonspecific antineoplastic agent Use generic topiramate Full Prior Authorization table available at: CLINICAL PRACTICE GUIDELINE UPDATE Clinical Practice Guideline Academy/Association Comment 2013 ACC/AHA Guideline on the American Heart Association Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults IMPORTANT INFORMATION ABOUT IEHP CLINICAL PRACTICE GUIDELINES IEHP publishes and distributes an IEHP Book to our Providers every year. The IEHP 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 literatures. They do not favor any particular drug based solely on cost considerations. All guidelines for therapy 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 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 Chronic Kidney Disease

5 Depression Guideline and Toolkit Diabetes Mellitus Diabetes Pregnancy Fibromyalgia Gastroesophageal Reflux Disease Hepatitis C Hyperlipidemia Hypertension IVIG Migraine Multiple Sclerosis Osteoarthritis Pulmonary Arterial Hypertension Pain Management Respiratory Syncytial Virus Rheumatoid Arthritis Sexually Transmitted Diseases- Summary of CDC Treatment Guidelines Smoking Cessation Synagis Criteria Season 2013/2014 We welcome any recommendations and comments regarding the IEHP. For questions, suggestions, or if you would like a printed copy of the IEHP Book or Clinical Practice Guideline, please call us at (909) As a reminder, updated formulary information and Clinical Practice Guidelines are available at Sincerely, IEHP Pharmaceutical Services