August 29, 2012.
Subject:
August 2012
2 LA Care Form
mulary Update
es
Dear Practtitioner:
We would like to thank yo
ou for providing
g quality service
es to our LA Care Medi-Cal, Healthy Kids, Healthy
H
Familie
es and
IHSS mem
mbers.
LA Care’s Pharmacy, The
erapeutics and New Technolo
ogy (PT&T) Co
ommittee review
wed several dru
ugs on August 9, 2012.
cation is to info
orm you of the changes.
c
The results listed below
b
will be effective
e
startin
ng on
The purposse of this notific
Septemberr 14, 2012. Ple
ease, transition
n your memberss from non-form
mulary to the formulary alterrnatives if apprropriate.
Form
mulary
Staatus
Po
otential Formularry alternative(s), Step
S
Theerapy Medication
n(s), or other Editt(s) if
appllicable
Pramipexole ER
E
F/S
ST
p with pramipexxole IR, ropiniro
ole IR
Step
and ropinirole ER
Ropinirole ER
F/S
ST
Step with rop
pinirole IR and
pramip
pexole IR
Drug Name
Mirapex ER
R
Geneeric Name
Nasonex
Mometasone furoate
f
N
NF
Remove fro
om formulary
Veramyst
Fluticasone
N
NF
Remove fro
om formulary
F
Add to formulary
f
Malathion .5%Lotion
F/S
ST
Step with perme
S
ethrin, Eurax and
a
Lindane. LAC0
01 also require
es
piperonyl buto
oxide/pyrethrinss
Calcipotriene
F/Q
QL
Q 4 tubes of 30gm per co-p
QL=
pay
Calcipotriene
N
NF
Rem
move from form
mulary, use 30g
g tube
Calcipotriene 0.005%
0
ointme
ent
F/S
ST
Step of Dovonex 0.005%
0
Cream
m 30gtu
ube
Calcipotriene 0.005%
0
solution
F/S
ST
0
Cream
m 30gStep of Dovonex 0.005%
tu
ube
NF//PA
Add Prior Authorization
A
F
R
Remove
ST and
d remove age edit
e
N
NF
Remove fro
om formulary
Triamcinolone acetonide
Dovonex .0
005%Cr
30g
Dovonex .0
005% Cr
60g and 12
20g
Tinidazole
Montelukast so
odium
Detrol LA
Tolterodine tarrtrate ER
Drug Name
Enablex
Geneeric Name
Darifenacin hyydrobromide
Alfuzosin
Form
mulary
Staatus
F/P
PA
Po
otential Formularry alternative(s), Step
S
Theerapy Medication
n(s), or other Editt(s) if
appllicable
Adde
ed to Formularry with PA.
F
Onglyza
Saxagliptin
N
NF
Re
emove from forrmulary. Preferrred
ag
gents are Janu
uvia and Tradje
enta
Kombiglyze
e XR
Saxagliptin/Me
etformin
N
NF
Re
emove from forrmulary. Preferrred
age
ents are Janum
met/Janumet XR
R and
Jenta
adueto
Januvia/Ja
anumet/XR
Sitagliptin/ Sita
agliptin/metform
min
F/ST
T/QL
Step with any metformin
Tradjenta/JJentadueto
Linagliptin/Lin--metformin
F/ST
T/QL
Step with any metformin
First-lansoprazole
Lansoprazole
F/P
PA
First-omep
prazole
Omeprazole
F/P
PA
Dexilant
Dexlansoprazo
ole
F/S
ST
Ste
ep with omepra
azole, pantopra
azole,
and OTC la
ansoprazole.
Prevacid 24 HR
(OTC)
Lansoprazole
F/S
ST
Step with om
meprazole and
pantoprazole
F/ST
T/QL
ST with zolpidem
z
IR
Q
QL
<18 yo=3 inh
halers/30 days
Zolpidem tartra
ate CR
Ventolin HF
FA
Albuterol HFA
≥18 yo= 2 inh
halers/30 days
If you belie
eve that your pa
atients need to be on non-form
mulary medica
ations or require
e an exception for Quantity
Limitationss or Step Thera
apy requiremen
nts, please do one
o of the follow
wing:
1.
Fa
ax a completed
d Medication Request
R
Form to
o MedImpact at
a 1-800-681-7
7651, OR
2.
Contact MedImp
pact at (800) 78
88-2949 and prrovide all necessary informatiion requested and
a
fo
ollowed with a signed
s
MRF within one busine
ess day.
This inform
mation is being provided for general
g
informa
ation purposess only and is not
n intended ass a substitute for
f the
independent medical judgment of a pra
actitioner. Onlly the treating practitioner ca
an determine what
w
medication
ns are
e for their patie
ent(s).
appropriate
Electronic version
v
of LA Care’s
C
Formula
ary and other Formulary
F
Upda
ates are alwayss available online at
http://www.lacare.org.
Thank you again for work
king with LA Ca
are to provide our
o members with
w quality hea
althcare.
H
Plan
L.A. Care Health
Pharmacy and Formulary
y Department