20-140 Medication Trend Updates and Formulary Changes - 1st Quarter 2020
Date: 02/11/20
This information applies to Physicians and Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Review changes that improve patient safety and encourage medication adherence
Stay up to date with information about:
- Patent expiration for commonly used brand-name medications
- Changes to the Health Net* commercial Formulary, Medi-Cal Preferred Drug List (PDL) and Medicare Part D Formulary for the first quarter of 2020.
Patent expiration for commonly used brand-name medications
Patents are granted by the United States Patent and Trademark Office along the development lifeline of a medication. Patents expire 20 years from the date of filing. Many factors can affect the duration of a patent. When a brand-name medication loses its patent, lower-priced generics enter the market. U.S. Food & Drug Administration (FDA)-approved generic drugs are made under the same rigorous standards as their brand-name counterparts and are bioequivalent. In other words, they deliver the same amount of active ingredients into a patient's bloodstream in the same amount of time as their brand-name product. During the upcoming year, the medications below are anticipated to be available as generic equivalents.
Medication patent expirations 2020 | |
1st Quarter | Noxafil®1, Zortress® |
2nd Quarter | Travatan Z® |
3rd Quarter | Truvada®, Atripla® |
4th Quarter | Absorica®1, Chantix®, Dulera®1, Jadenu® |
1 Nonformulary
Changes to the commercial Formulary, Medi-Cal PDL and Medicare Part D Formulary
The Health Net Pharmacy and Therapeutics (P&T) Committee, which includes practicing physicians, pharmacists and other health care professionals, reviews medications on the Formulary for commercial members, PDL for Medi-Cal members and the Medicare Part D Formulary for Medicare members each quarter to determine medications to stay on or be moved to a different tier. A list of some recent changes is provided in a table beginning on page 3. The list contains brand-name prescription medications, status, other medication choices, and comments for the first quarter of 2020.
Complete lists of the commercial Formularies, Medi-Cal PDLs and Medicare Part D Formularies are available on the Health Net provider websites listed below, then go to Pharmacy Information.
Pharmacy help line
For more information regarding changes to the Health Net commercial Formulary, Health Net Medi-Cal PDL or Medicare Part D Formulary, contact the applicable pharmacy telephone number listed below:
- Pharmacy Services (commercial): 1-800-548-5524, option #3; fax 1-800-314-6223
- Pharmacy Service Center (Medi-Cal, Medicare and Cal MediConnect): 1-800-867-6564; fax 1-800-977-8226
- Health Net Clinical Pharmacy Line (clinical programs): 1-800-782-2221
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center by email at provider_services@healthnet.com within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
EnhancedCare PPO (IFP) | 1-844-463-8188 | provider_services@healthnet.com | |
EnhancedCare PPO (SBG) | 1-844-463-8188 | ||
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | ||
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | ||
Medicare (individual) | 1-800-929-9224 | ||
Medicare (employer group) | 1-800-929-9224 | ||
Medi-Cal | 1-800-675-6110 | N/A |
Health Net Commercial Formulary, Medi-Cal PDL and Medicare Part D Formulary Changes
Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value2 | Medi-Cal | Commercial | Medicare | Medi-Cal | ||
ORAL MEDICATIONS | |||||||
Aemcolo™ (rifamycin) delayed-release tablet | NF QL (NF QL) | NF | NF | ciprofloxacin, levofloxacin, ofloxacin, azithromycin | ciprofloxacin, levofloxacin, ofloxacin, azithromycin | ciprofloxacin, levofloxacin, ofloxacin, azithromycin | Treatment of travelers’ diarrhea (TD) caused by noninvasive strains of Escherichia coli in adults. Limitation(s) of use: Aemcolo is not indicated in patients with diarrhea complicated by fever or bloody stool or due to pathogens other than noninvasive strains of Escherichia coli. For commercial line of business, quantity limit is 12 tablets per fill. |
Nubeqa® (darolutamide) tablet | Tier 2* (SP*) | Tier 5 (* for new start only) | NF | Anti-androgens: bicalutamide (Casodex®), flutamide, and nilutamide (Nilandron®)
| Anti-androgens: bicalutamide (Casodex), flutamide, and nilutamide (Nilandron) Luteinizing hormone-releasing hormone (LHRH) agonists: Zoladex® (goserelin), Eligard® (leuprolide) LHRH antagonist: Firmagon® (degarelix) | Anti-androgens: bicalutamide (Casodex)**, flutamide**
| Treatment of patients with non-metastatic castration resistant prostate cancer (nmCRPC) |
Piqray® (alpelisib) tablet | Tier 3* (SP*) | Tier 5 (* for new start only) | NF | Endocrine therapy: anastrozole (Arimidex®), exemestane (Aromasin®), letrozole (Femara®), megestrol acetate, tamoxifen (Nolvadex®), toremifene (Fareston®)
| Endocrine therapy: anastrozole (Arimidex), exemestane (Aromasin), letrozole (Femara), megestrol acetate, tamoxifen (Nolvadex)
| Endocrine therapy: anastrozole (Arimidex)**, exemestane (Aromasin)**, letrozole (Femara)**, megestrol acetate**, tamoxifen (Nolvadex)**, toremifene (Fareston)** | In combination with fulvestrant for the treatment of postmenopausal women, and men, with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative, PIK3CA-mutated, advanced or metastatic breast cancer as detected by an FDA-approved test following progression on or after an endocrine-based regimen |
Sunosi™ (solriamfetol) tablet | NF (NF) | Tier 4* (QL) | NF | Narcolepsy, OSA: armodafinil (Nuvigil®)* Narcolepsy: amphetamine immediate-release (IR), amphetamine/ dextroamphetamine (Adderall®), dextroamphetamine (Dexedrine®), methylphenidate (Ritalin®) | Narcolepsy, OSA: armodafinil (Nuvigil)*, modafinil (Provigil®)* Narcolepsy: amphetamine immediate-release (IR), amphetamine/ dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), methylphenidate (Ritalin) | Narcolepsy, OSA: armodafinil (Nuvigil)*, modafinil (Provigil)* Narcolepsy: amphetamine immediate-release (IR), amphetamine/ dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), methylphenidate (Ritalin) | To improve wakefulness in adult patients with excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea (OSA) For Medicare, quantity limit is 2 tablets per day (for 75 mg tablet) and 1 tablet per day (for 100 mg tablet). |
Turalio™ (pexidartinib) capsule | Tier 2* (SP*) | Tier 5 (* for new start only)
| NF |
|
|
| Treatment of adult patients with symptomatic tenosynovial giant cell tumor (TGCT) associated with severe morbidity or functional limitations and not amenable to improvement with surgery |
Xpovio™ (selinexor) tablet | Tier 3* (SP *) | Tier 5 (* for new start only) | NF | Proteasome inhibitors: Ninlaro®* (Tier 3 plan) Immunomodulatory agents: Revlimid®* (Tier 3 plan)
|
| Proteasome inhibitors: Ninlaro*,** Immunomodulatory agents: Pomalyst®** Anti‐CD38 monoclonal antibody: Darzalex®* | In combination with dexamethasone for the treatment of adult patients with relapsed or refractory multiple myeloma (RRMM) who have received at least four prior therapies and whose disease is refractory to at least two proteasome inhibitors, at least two immunomodulatory agents, and an anti‐CD38 monoclonal antibody |
Zelnorm® (tegaserod maleate) tablet | NF (NF) | NF | NF | polyethylene glycol (MiraLax®), Amitiza®, Linzess® | polyethylene glycol (MiraLax), Amitiza, Linzess | polyethylene glycol (MiraLax) Bulk-forming laxative: psyllium (Metamucil®), methylcellulose powder (Citrucel®), calcium polycarbophil (FiberCon®) Stimulant laxative: bisacodyl | Treatment of adult women less than age 65 with irritable bowel syndrome with constipation (IBS-C) |
VAGINAL PREPARATIONS | |||||||
Annovera™ (segesterone acetate and ethinyl estradiol) vaginal ring | NF (NF) | NF | NF | Nuvaring® Oral contraceptives: ethinyl estradiol/ norethindrone (Junel®, Necon®, Ortho-Novum®) ethinyl estradiol/ levonorgesterol (Lessina®) ethinyl estradiol/ norgesterol (Cryselle™, Ogestrel®) ethinyl estradiol/ ethynodiol (Kelnor®, Zovia®) ethinyl estradiol/ desogestrel (Mircette®) ethinyl estradiol/ drospirenone (Yasmin®) ethinyl estradiol/ norgestimate (Ortho-Cyclen®) | Nuvaring Oral contraceptives: ethinyl estradiol/ norethindrone (Junel, Ortho-Novum) ethinyl estradiol/ levonorgesterol (Lessina) ethinyl estradiol/ norgesterol (Cryselle) ethinyl estradiol/ ethynodiol (Kelnor, Zovia) ethinyl estradiol/ desogestrel (Mircette) ethinyl estradiol/ drospirenone (Yasmin) ethinyl estradiol/ norgestimate (Ortho-Cyclen) | Nuvaring Oral contraceptives: ethinyl estradiol/ norethindrone (Junel, Necon, Ortho-Novum) ethinyl estradiol/ levonorgesterol (Lessina) ethinyl estradiol/ norgesterol (Cryselle, Ogestrel) ethinyl estradiol/ ethynodiol (Kelnor, Zovia) ethinyl estradiol/ desogestrel (Mircette) ethinyl estradiol/ drospirenone (Yasmin) ethinyl estradiol/ norgestimate (Ortho-Cyclen) | For use by females of reproductive potential to prevent pregnancy |
INJECTABLE PREPARATIONS | |||||||
Ultomiris™ (ravulizumab-cwvz) single-dose vial | Medical benefit (Medical benefit) | NF | NF |
|
| Soliris® * | Treatment of adult patients with paroxysmal nocturnal hemoglobinuria (PNH) |
Vyleesi™ (bremelanotide) single-dose prefilled autoinjector | Medical benefit (NF) | Medicare excluded | NF |
|
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| Treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD) as characterized by low sexual desire that causes marked distress or interpersonal difficulty and NOT due to: • A co-existing medical or psychiatric condition, • Problems with the relationship, or • The effects of a medication or drug substance. |
2Medicare Part D Value Formulary = Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Healthy Heart (HMO)
*Prior authorization (PA) is required to verify member eligibility and that the member satisfies clinical protocols to ensure appropriate use of the medication.
**CCS = California Children’s Services: refer to www.dhcs.gov for the local telephone number to determine member’s coverage eligibility.
- F indicates formulary.
- NF indicates nonformulary. These medications require member-specific medical reasons why formulary medications cannot be considered. Requests are reviewed via Health Net's prior authorization process.
- SP indicates specialty tier.
- QL indicates quantity limit.