20-580 Stay Up to Date with Medication Trend Updates and Formulary Changes - 3rd Quarter 2020
Date: 07/30/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
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:
- Zero copayment program for Medicare Advantage (MA) members
- Weight-loss drugs Belviq® and Belviq XR® (lorcaserin) withdrawn from the market due to cancer risk
- Changes to the Health Net* commercial Formulary, Medi-Cal Preferred Drug List (PDL) and Medicare Part D Formulary for the third quarter of 2020.
Weight-loss drugs Belviq and Belviq XR withdrawn from the market due to cancer risk
On February 13, 2020, the U.S. Food and Drug Administration (FDA) requested that Eisai Inc., the maker of Belviq and Belviq XR (lorcaserin), withdraw the drug from the U.S. market because a safety clinical trial showed an increased risk of cancer. Eisai Inc. has submitted a request to voluntarily withdraw the drug.
Lorcaserin was first approved by the FDA in 2012 as an add-on therapy to help aid weight loss, along with diet and exercise, in people who were obese or overweight and have weight-related medical problems. Lorcaserin works by increasing feelings of fullness so that less food is eaten. It is available as a tablet (Belviq) and an extended-release tablet (Belviq XR).
When the FDA approved lorcaserin in 2012, the FDA required the drug manufacturer to conduct a clinical trial to evaluate the risk of cardiovascular problems. A range of cancer types was reported, with several different types of cancers occurring more frequently in the lorcaserin group, including pancreatic, colorectal and lung. On January 15, 2020, the FDA announced that Belviq might have links to cancer and concluded that the potential risks of lorcaserin outweigh its benefit. FDA’s analysis found that about 7.7% of Belviq patients had cancer diagnoses, compared with 7.1% of patients who received a placebo.
Health professionals should stop prescribing and dispensing lorcaserin to patients. Inform the patients currently taking lorcaserin of the increased occurrence of cancer seen in the clinical trial, and ask them to stop taking the medicine. They should discuss alternative weight-loss medicines or strategies with their patients.
Zero copayment program for Medicare Advantage members
Health Net continues to encourage member medication adherence and offers zero copayment on some medications to help alleviate barriers to medication adherence and help members better manage their chronic diseases. Most of the medications listed below – in the statins, anti-diabetic agents (not including insulin), angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blocker (ARB) medication classes – are included on the Select Care tier without copayments for MA members. Members should contact the Health Net Medicare Programs Member Services Department, as listed on the member identification (ID) card, to ensure deductibles have been met.
Zero-Copayment Medications for Medicare Advantage Members | |||
Class | Medication | ||
Lipid management (statins) |
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Anti-diabetic agents
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ACEIs/ARBs
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- SR – sustained release, XR – extended release, HCI – hydrochloride, HCTZ – hydrochlorothiazide
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 third 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 in the Additional Information section. 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 about the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by telephone or through the Health Net provider website:
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
Oral medications
| Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
| Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value1 | Medi-Cal | Commercial (Tier 1 or 2) | Medicare Part D Value1 (Tier 1, 2, 3, 4, 5 or 6) | Medi-Cal | ||
| Ayvakit™ (avapritinib) tablet | Tier 3 QL* (Specialty Tier QL*) | Tier 5 (* for new starts only) | NF | imatinib (Gleevec®) (under Tier 3 plan) | imatinib (Gleevec)*** | imatinib (Gleevec)** | Treatment of adults with unresectable or metastatic gastrointestinal stromal tumor (GIST) harboring a platelet-derived growth factor receptor alpha (PDGFRA) exon 18 mutation, including PDGFRA D842V mutations Quantity limit is 1 tablet per day |
| Brukinsa® (zanubrutinib) capsule | Tier 3* (Specialty Tier *) | Tier 5 (* for new starts only) | NF | Imbruvica®* (under Tier 3 plan) | Calquence®***, Imbruvica*** | Calquence*,** Imbruvica*,** | Treatment of adult patients with mantle cell lymphoma (MCL) who have received at least one prior therapy |
| Caplyta® (lumateperone) capsule | NF (NF) | Tier 5 (* for new starts only) | Bill Medi-Cal fee for service directly | aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone | aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone, Latuda®***, paliperidone (Invega®), Rexulti®***, Saphris®, Vraylar®*** | Treatment of schizophrenia in adults Quantity limit is 1 tablet per day | |
| Oxbryta™ (voxelotor) tablet | NF (NF) | Tier 5* | NF | hydroxyurea | hydroxyurea | hydroxyurea** | Treatment of sickle cell disease (SCD) in adults and pediatric patients 12 years of age and older |
| Palforzia™ (peanut allergen powder-dnfp) capsule or sachets | NF (NF) | Bill under Part B | NF | Mitigation of allergic reactions, including anaphylaxis, that may occur with accidental exposure to peanut. Palforzia is approved for use in patients with a confirmed diagnosis of peanut allergy. Initial dose escalation may be administered to patients ages 4 through 17. Up-dosing and maintenance may be continued in patients ages 4 and older. Palforzia is to be used in conjunction with a peanut-avoidant diet. | |||
| Reyvow™ (lasmiditan) tablet | NF QL (Specialty Tier QL*) | NF (QL) | NF | almotriptan, naratriptan, rizatriptan, sumatriptan | almotriptan, naratriptan, rizatriptan, sumatriptan | almotriptan, naratriptan, sumatriptan | Acute treatment of migraine with or without aura in adults Limitation(s) of use: Reyvow is not indicated for the preventive treatment of migraine. Quantity limit is 4 tablets per month for 50mg and 8 tablets per month for 100mg |
| Rinvoq™ (upadacitinib) extended-release tablet | Specialty Tier* (Specialty Tier *) | Tier 5* | NF | Disease-modifying anti-rheumatic drugs (DMARDs): methotrexate, hydrochloroquine, leflunomide, sulfasalazine Preferred biologic DMARDs at Specialty Tier*: Humira® and Enbrel® followed by Xeljanz® or Xeljanz® XR | DMARDs: methotrexate, hydrochloroquine, leflunomide, sulfasalazine Biologic DMARDs*: Humira, Enbrel, Xeljanz, Xeljanz XR, Remicade®, Simponi Aria® | DMARDs: methotrexate**, hydrochloroquine, leflunomide, sulfasalazine Biologic DMARDs*: Humira**, Enbrel**, Xeljanz, Xeljanz XR, Orencia®**, Remicade**, Simponi Aria** | Treatment of adults with moderately to severely active rheumatoid arthritis (RA) who have had an inadequate response or intolerance to methotrexate |
| Tazverik™ (tazemetostat) tablet | Tier 3* (Specialty Tier *) | Tier 5 (* for new starts only) | NF | doxorubicin, dacarbazine, ifosfamide, epirubicin, gemcitabine, mesna, vinorelbine | doxorubicin* | Treatment of adults and pediatric patients ages 16 and older with metastatic or locally advanced epithelioid sarcoma (ES) not eligible for complete resection | |
| Truvada® (emtricitabine 200 mg/ tenofovir disoproxil fumarate 300 mg) tablet | Tier 2 (Tier 2) | Tier 5 | Bill Medi-Cal fee for service directly | In combination with safer sex practices for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in adults at high risk. For commercial members, Truvada will process at a zero copay when used for PrEP as members renew after June 11, 2020. | |||
Topical preparations
| Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
| Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value1 | Medi-Cal | Commercial (Tier 1 or 2) | Medicare Part D Value1 (Tier 1, 2, 3, 4, 5 or 6) | Medi-Cal | ||
| Aklief® (trifarotene) cream | NF (NF) | NF | NF | adapalene, tazarotene, tretinoin | adapalene, tazarotene, tretinoin | adapalene, tazarotene, tretinoin | Topical treatment of acne vulgaris in patients ages 9 and older |
Injectable preparations
| Medication | Status | Health Net Formulary Alternative(s) | Comments | ||||
| Commercial 3-Tier Plan (4-Tier Plan) | Medicare Part D Value1 | Medi-Cal | Commercial (Tier 1 or 2) | Medicare Part D Value1 (Tier 1, 2, 3, 4, 5 or 6) | Medi-Cal | ||
| Adakveo® (crizanlizumab-tmca) single-dose vial | Medical benefit | Tier 5* | Medical benefit* | hydroxyurea | hydroxyurea | hydroxyurea** | To reduce the frequency of vaso-occlusive crises (VOC) in adults and pediatric patients ages 16 and older with sickle cell disease (SCD) |
| Reblozyl® (luspatercept-aamt) single-dose vial | Medical benefit | Tier 5* | Medical benefit* | Treatment of anemia in adult patients with beta thalassemia who require regular red blood cell (RBC) transfusions | |||
| Scenesse® (afamelanotide) implant | Medical benefit | Tier 5* | Medical benefit* | To increase pain-free light exposure in adult patients with a history of phototoxic reactions from erythropoietic protoporphyria (EPP) | |||
| Skyrizi™ (risankizumab-rzaa) prefilled syringe | Specialty Tier* (Specialty Tier *) | Tier 5*, GF | NF | methotrexate, cyclosporine Preferred biologic DMARDs at Specialty Tier*: Humira, Enbrel, Otezla®, Cosentyx® (Tier 4 plan only) | methotrexate, cyclosporine Biologic DMARDs*: Humira, Enbrel, Remicade, Simponi Aria | methotrexate**, cyclosporine** Biologic DMARDs*: Humira**, Enbrel**, Otezla, Cosentyx, Remicade**, Simponi Aria** | Treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy |
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.
- GF indicates drug will pay for the duration of the benefit year for members currently taking the drug.
- 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.