20-371 Stay Up to Date with Medication Trend Updates and Formulary Changes - 2nd Quarter 2020
Date: 05/08/20
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:
- Safety communication alert on gabapentin and pregabalin.
- Osteoporosis member outreach reports.
- Alternative sites of infusion care for commercial and Medi-Cal members.
- Medi-Cal prior authorization requests for Humira®.
- Changes to the guidelines for provision of methadone and buprenorphine for treating opioid use disorder (OUD)† related to the COVID-19 emergency.
- Changes to the Health Net* commercial Formulary, Medi-Cal Preferred Drug List (PDL) and Medicare Part D Formulary for the second quarter of 2020.
Safety communication alert about gabapentin and pregabalin
The U.S. Food and Drug Administration (FDA) is warning that serious breathing difficulties may occur in patients with respiratory risk factors using gabapentin (Neurontin®, Gralise®, Horizant®) or pregabalin (Lyrica®, Lyrica® CR). These FDA-approved medications are used to treat a variety of conditions, including seizures, postherpetic neuralgia (pain following shingles), neuropathic pain associated with diabetic neuropathy, fibromyalgia, generalized anxiety disorder, and restless legs syndrome. The FDA is requiring new warnings to be added to the prescribing information of these medications, which are often referred to as gabapentinoids.
The warning is for individuals who have concurrent respiratory risk factors, which include combined use of opioids or other drugs that depress the central nervous system (CNS), conditions, such as chronic obstructive pulmonary disease (COPD), that reduce lung function, and older age. Gabapentinoids are often being combined with CNS depressants, which increases the risk of respiratory depression. CNS depressants include opioids, anti-anxiety medicines, antidepressants, and antihistamines. Fewer breathing complications were seen in healthy individuals taking gabapentinoids alone. The new warnings are based on a review of data from numerous sources, including case reports, observational studies, human trials and animal studies.
The FDA recommends that health care professionals start gabapentinoids at the lowest dose and monitor patients for symptoms of respiratory depression and sedation when gabapentinoids are prescribed with an opioid or other CNS depressants. Individuals with underlying respiratory disease and the elderly are also at increased risk and should be managed similarly.
Osteoporosis member outreach reports available
The Management of Post-Menopausal Women with Osteoporotic Fractures Program is a health education outreach and intervention for Health Net Medicare Advantage (MA) members ages 65 to 85 who have had an osteoporotic fracture in the past three months and have not received a bone-mineral density (BMD) test or are not currently taking prescription medication.
PPGs can access reports with specific Healthcare Effectiveness Data and Information Set (HEDIS®) results to find areas for improvement or best practices. The report provides monthly gap lists for specific measures to find gaps in data and drive member gap closure. These reports are available on the Health Net provider portal, as listed in the right-hand column on page 1. For technical help on how to gain access to these reports, contact Health Net's Web Support at 1-866-458-1047.
Alternative sites of infusion care for commercial and Medi-Cal members
The plan has options available for members who are being treated with any of the infusion products listed in the table below. Members have the option to transition infusions from the hospital to the home, an ambulatory infusion suite (AIS) or a nearby physician’s office. Alternate site of infusion care is part of a member's standard benefits.
Health Net has partnered with Coram® CVS Specialty™ Infusion Services as the designated provider for these infusions. Coram provides:
- Experience. More than 30 years of experience in specialized infusion care and demonstrated expertise in the delivery and administration of complex specialty infused medications.
- Safety. Clinicians are certified and specialize in delivery of chronic and complex drug therapy and careful patient monitoring. Experienced nurses stay for the entire infusion duration ensuring patients receive high-level care.
- Convenience. In-home and AIS-based infusions are scheduled directly with patients, enabling flexibility, independence and enhanced quality of life. Clinical support is available to patients 24 hours a day, seven days a week.
- Lower costs. Infusions may be provided at a lower cost to patients promoting compliance to therapy and ultimately improve outcomes and reduce health costs.
For patient referrals or additional information, contact Peter Tran, PharmD, at (714) 934-3362, Monday through Friday, from
9 a.m. to 4 p.m., and reference the Site of Care Optimization of Therapeutic Infusion (SCOTI) Program.
Products eligible for alternate site of infusion care
Disorder | Product | Disorder | Product |
Alpha-1 antitrypsin deficiency | Aralast™ NP, Glassia®, Prolastin®-C, Zemaira® | Lysosomal storage disorders | Aldurazyme®, Cerezyme®, Elaprase®, Elelyso®, Fabrazyme®, Kanuma®, Lumizyme®, Naglazyme®, Vimizim®, Vpriv® |
Amyloidosis | Onpattro® | Movement disorders | Radicava® |
Autoimmune disorders | Actemra®, Entyvio®, Inflectra®, Orencia®, Remicade®, Renflexis®, Simponi Aria® | Multiple sclerosis | Lemtrada®, Ocrevus®, Tysabri® |
Hereditary angioedema | Cinryze® | Paroxysmal nocturnal hemoglobinuria | Soliris®, Ultomiris® |
Immune deficiencies and related disorders
| Asceniv®, Bivigam®, Carimune®, Cutaquig®, Cuvitru®, Flebogamma®, Gammagard® Liquid, Gammagard® S/D, Gammaked™, Gammaplex®, Gamunex®-C, Hizentra®, Hyqvia®, Octagam®, Panzyga®, Privigen®, Xembify® | ||
Rare disorders | Crysvita® | ||
Systemic lupus erythematosus | Benlysta® |
Medi-Cal prior authorization requests for Humira
For Health Net Medi-Cal members, note the following changes to the PA requirements for Humira. For Crohn’s disease, ulcerative colitis, hidradenitis suppurativa, and uveitis, Humira remains a preferred medication.
| Indication | Preferred medication(s)* |
Rheumatoid arthritis | Two of the following, each used for at least three months: Enbrel®, Kevzara®, Xeljanz®/Xeljanz XR® |
Polyarticular juvenile idiopathic arthritis | Enbrel used for at least three months |
Psoriatic arthritis | Three of the following, each used for at least three months: Enbrel, Otezla®, Simponi®/Simponi Aria, Taltz®, Xeljanz/Xeljanz XR |
Ankylosing spondylitis | Two of the following, each used for at least three months: Cimzia®, Enbrel, Taltz |
Plaque psoriasis | Taltz used for at least three months |
*Prior authorization (PA) is required to verify member eligibility and that the member satisfies clinical protocols to ensure appropriate use of the medication.
Changes to guidelines for provision of methadone and buprenorphine for the treatment of OUD
The Substance Abuse and Mental Health Services Administration (SAMHSA) has released a set of FAQs about changes to the guidelines for provision of methadone and buprenorphine for OUD in light of the COVID-19 emergency. To view the FAQs, visit www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf.
Also, for Medi-Cal, the Department of Health Care Services (DHCS) has released FAQs pertaining to medication-assisted treatment and telehealth. To view the FAQs, visit www.dhcs.ca.gov/provgovpart/Documents/COVID-19-FAQ-MAT-and-Telehealth_CSD.pdf.
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 below. The list contains brand-name prescription medications, status, other medication choices, and comments for the second 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 as listed below. Once on the website, the lists are viewable under 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 |
†Any transfer of information or data between providers and/or facilities about a member’s OUD or SUD must first be authorized by the member before transferring the information or data between providers and/or facilities. This can be done by having the member sign an Authorization for Disclosure (AFD) form and designating the provider or entity that will be reviewing the member’s data.
Health Net Commercial Formulary, Medi-Cal PDL and Medicare Part D Formulary Changes
Oral medications
Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value1 | Medi-Cal | Commercial | Medicare | Medi-Cal | ||
Mayzent® (siponimod) tablet | Tier 3* (NP*) | Tier 5* | F* | Injectable formulation: glatiramer (Copaxone®)* (for Tier 4 plan), Glatopa®* (for Tier 4 plan) |
| Oral formulation: Gilenya®*,**, Tecfidera®*,** Injectable formulation: glatiramer (Copaxone)*,**, Glatopa*,**, Avonex®*, Plegridy®*,** | Treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome (CIS), relapsing-remitting disease (RRMS) and active secondary progressive disease (SPMS), in adults |
Nourianz™ (istradefylline) tablet | NF (NF) | NF | NF | entacapone, pramipexole, rasagiline, ropinirole | entacapone, pramipexole, rasagiline, ropinirole, tolcapone, Neupro® | entacapone, pramipexole, ropinirole | As adjunctive treatment to levodopa/carbidopa in adult patients with Parkinson’s disease (PD) experiencing “off” episodes |
Pretomanid tablet | NF (NF) | Tier 4* | NF |
|
|
| Treatment of adults with pulmonary extensively drug resistant (XDR), treatment-intolerant or nonresponsive multidrug-resistant (MDR) tuberculosis (TB) as part of a combination regimen with bedaquiline and linezolid
|
Trikafta™ | Tier 3* (Specialty Tier*) | Tier 5* | F* |
|
| Kalydeco®*, **, Orkambi®*, **, Symdeko®*, ** | Treatment of cystic fibrosis (CF) in patients age 12 and older who have at least one F508del mutation in the cystic fibrosis transmembrane conductance regulator (CFTR) gene |
Vyndaqel®(tafamidis 20 mg) and Vyndamax™ (tafadimis 61 mg) capsule | Tier 3* QL (SP* QL) |
Tier 5* QL |
F* QL |
|
|
| Treatment of the cardiomyopathy of wild type or hereditary transthyretin-mediated amyloidosis (ATTR-CM) in adults to reduce cardiovascular mortality and cardiovascular-related hospitalization Quantity limit is 4 capsules per day (Vyndaqel) and 1 capsule per day (Vyndamax). |
Wakix®(pitolisant) tablet | NF (NF) | Tier 5* | NF | armodafinil (Nuvigil®)* Stimulants: amphetamine immediate-release (IR), amphetamine/ dextroamphetamine (Adderall®), dextroamphetamine (Dexedrine®), methylphenidate (Ritalin®) | armodafinil (Nuvigil)*, modafinil (Provigil®)* Stimulants: amphetamine immediate-release (IR), amphetamine/ dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), methylphenidate (Ritalin) | armodafinil (Nuvigil)*, modafinil (Provigil®)* Stimulants: amphetamine immediate-release (IR), amphetamine/ dextroamphetamine (Adderall), dextroamphetamine (Dexedrine), methylphenidate (Ritalin) | Treatment of excessive daytime sleepiness (EDS) in adult patients with narcolepsy |
Xenleta™ (lefamulin) tablet | NF (NF) | Tier 5 * | NF | azithromycin, erythromycin, clarithromycin, doxycycline, amoxicillin, amoxicillin/ clavulanate, cefdinir, cefpodoxime, cefuroxime, levofloxacin, moxifloxacin | azithromycin, erythromycin, clarithromycin, doxycycline, amoxicillin, amoxicillin/ clavulanate, cefdinir, cefpodoxime, cefuroxime, levofloxacin, moxifloxacin | azithromycin, erythromycin, clarithromycin, doxycycline, amoxicillin, amoxicillin/ clavulanate, cefdinir, cefpodoxime, cefuroxime, levofloxacin | Treatment of adults with community-acquired bacterial pneumonia (CABP) caused by the following susceptible microorganisms: Streptococcus pneumoniae, Staphylococcus aureus (methicillin-susceptible isolates), Haemophilus influenzae, Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae |
Inhalation preparations
Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value1 | Medi-Cal | Commercial | Medicare | Medi-Cal | ||
Breo® Ellipta® (fluticasone furoate and vilanterol inhalation powder) inhaler | Tier 2 QL (Tier 2 QL) | Tier 3 QL | F (ST) |
|
| fluticasone/ salmeterol (Advair Diskus®), Symbicort® | Step therapy requires a trial of fluticasone/salmeterol (Advair Diskus) or Symbicort first. Quantity limit is one inhaler per month. |
Dulera® (mometasone furoate and formoterol fumarate dihydrate) inhaler | NF (NF) | NF | F (ST) | fluticasone/ salmeterol (Advair Diskus) | fluticasone/ salmeterol (Advair Diskus) | fluticasone/ salmeterol (Advair Diskus), Symbicort | Step therapy requires a trial of fluticasone/salmeterol (Advair Diskus) or Symbicort first. Quantity limit is one inhaler per month. |
Symbicort (mometasone furoate and formoterol fumarate dihydrate) inhaler | Tier 2 QL (Tier 2 QL) | Tier 3 QL | F |
|
|
| Quantity limit is one inhaler per month. |
Injectable preparations
Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value1 | Medi-Cal | Commercial | Medicare | Medi-Cal | ||
Beovu® (brolucizumab) single-dose vial | Medical benefit | Tier 5* | Medical benefit |
|
| Lucentis®*,** | Treatment of patients with neovascular (wet) age-related macular degeneration (nAMD) |
1Medicare 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.
- QL indicates quantity limit.
- SP indicates specialty tier.
- ST indicates electronic step therapy.