20-936m 2021 Individual Medicare Advantage Plan Codes, Service Area Changes and Medicare Part D Formulary
Date: 12/04/20
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
Review service area plan codes and see what’s changing in the Medicare formulary
Individual Medicare Advantage plan codes, county availability and Centers for Medicare & Medicaid Services contract identification numbers are provided on the 2021 Medicare Advantage Plan Codes by County flyer (PDF).
Use this new information to submit your monthly reporting.
2021 Changes
Effective January 1, 2021, the following plans change from 2020 to 2021:
- The Health Net Ruby Select Plan added to Placer and Sacramento County.
- The Health Net Amber II Premier (DSNP) Plan added to Sacramento County.
- The Healthy Heart Plan in Santa Clara is having a name change to the Ruby Plan.
2021 Available Optional Supplemental Packages
The nine optional supplemental packages and county availability are provided below.
Package# | Package name | Benefit highlights |
|---|---|---|
#1 | Enhanced dental and eye | Preventive and comprehensive dental, eyewear (benefits offered vary from package 2) |
#2 | Enhanced dental and eye flex | Preventive and comprehensive dental, eyewear (benefits offered vary from package 1) |
#3 | Enhanced dental | Preventive and comprehensive dental (benefits offered vary from package 4) |
#4 | Enhanced dental flex | Preventive and comprehensive dental (benefits offered vary from package 3) |
#5 | Essentials | Chiropractic, acupuncture, eyewear |
#6 | Fit | Chiropractic, acupuncture, eligible supplemental benefits, eyewear |
| #7 | Fit plus | Chiropractic, acupuncture, eligible supplemental benefits, comprehensive dental, eyewear |
| #8 | Total fit plus | Chiropractic, acupuncture, eligible supplemental benefits, preventive and comprehensive dental, eyewear (benefits offered vary from package 9) |
| #9 | Total fit flex | Chiropractic, acupuncture, eligible supplemental benefits, preventive and comprehensive dental, eyewear (benefits offered vary from package 8) |
Northern California
- Alameda
- Package # 4, 8, or 9.
- Fresno
- Package # 3 or 4.
- Placer
- Package # 3, 4, or 6.
- Sacramento
- Package # 3, 4, or 6.
- San Francisco
- Package # 7.
- Santa Clara
- Package # (none).
- Stanislaus
- Package # 4, 8, or 9.
- Yolo
- Package # 3, 4, or 5.
Southern California
- Imperial
- Package # 3 or 4.
- Kern
- Package # 3, or 4.
- Los Angeles
- Package # 1, 2, or 4.
- Orange
- Package # 1 or 2.
- Riverside
- Package # 1, 2, or 4.
- San Bernardino
- Package # 1, 2, or 4.
- San Diego
- Package # 3 or 4.
Medicare Part D
As of January 1, 2021, some drugs will no longer be covered on our Medicare formulary. To assist our providers, we have included a list of the most commonly prescribed drugs being removed along with the drug’s 2021 formulary alternative(s). Please refer to the list to identify the appropriate options for your patients.
If you determine that it is necessary for your patient to continue to receive the non-formulary drug in 2021, you will need to submit a Coverage Determination request on or after December 1, 2020.
Request forms are located on the Health Net Medicare Programs website on the Coverage Determinations and Redeterminations for Drugs page at ca.healthnetadvantage.com or you can call to request authorization.
If you have any questions, please contact Medicare Pharmacy Services at 1-800-867-6564.
Product Name | Formulary Alternative |
|---|---|
Cialis (applies to classic employer group formulary only) | Tadalafil |
Cimetidine | Famotidine, Nizatidine |
Fluticasone Propionate/Salmeterol Diskus, Wixela Inhub | Advair, Symbicort, Breo Ellipta, Trelegy Ellipta |
Gelnique Pump TD Gel | Oxybutynin Tabs, Oxybutynin ER Tabs |
Glyburide | Glipizide, Glimepiride |
Humalog Mix, Humalog Mix Kwikpen | Novolog Mix 70/30, Novolog 70/30 Flexpen |
Humalog, Humalog Junior Kwikpen, Humalog Kwikpen | Novolog INJ, Novolog Flexpen, Fiasp, Fiasp Flextouch |
Humulin 70/30, Humulin 70/30 Kwikpen | Novolin INJ 70/30, Novolin 70/30 Flexpen (Note: brand RELION not covered) |
Humulin N, Humulin N Kwikpen | Novolin N INJ U-100, Novolin N Flexpen (Note: brand RELION not covered) |
Humulin R | Novolin R, Novolin R Flexpen (Note: brand RELION not covered) |
Indomethacin | Ibuprofen, Meloxicam, Naproxen |
Invokana | Jardiance, Farxiga |
Lantus, Lantus Solostar | Basaglar, Levemir, Tresiba |
Omega-3-Acid Ethyl Esters | Vascepa |
Oxytrol TD Patch | Oxybutynin Tabs, Oxybutynin ER Tabs |
Premarin Crm, Premarin Tabs | Estradiol |
Proair HFA, Proair Respiclick | Ventolin HFA, Albuterol HFA |
Protonix Susp Pack | Pantoprazole Tabs, Lansoprazole Caps, Omeprazole Caps, Esomeprazole Caps |
Spiriva Handihaler, Spiriva Respimat | Incruse Ellipta, Trelegy Ellipta |
Stiolto Respimat | Anoro Ellipta, Bevespi Aerosphere, Trelegy Ellipta |
Testosterone Gel 1.62%, Testosterone Soln 30 MG/ACT | Testosterone Gel 1%, Testosterone Gel Pump 1% |
Toujeo Solostar, Toujeo Max Solostar | Basaglar, Levemi |
| Travatan Z | Travatan Z Sol 0.005%, Lumigan Sol 0.01%, Bimatoprost 0.03% |
Tudorza Pressair | Spiriva |
Vesicare | Solifenacin |