20-937m 2021 Plan Codes, Supplemental Benefits and Cal MediConnect 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 formulary
Two new plan codes have been assigned to the Cal MediConnect Plan
(Medicare-Medicaid Plan) as of January 1, 2021.
County | CMS1 Contract ID | Plan code |
|---|---|---|
Los Angeles | H3237-001 | HF0 (h-f-zero) |
San Diego | H3237-002 | HF1 |
1CMS – Centers for Medicare & Medicaid Services
Supplemental benefits
The following are lists of the supplemental benefits for 2021 by county:
Los Angeles County
- Vision ($250 eyewear allowance every two years)
- Non-medical transportation – Use of taxi, standard passenger vehicle or minivan to get medically necessary services. Unlimited round trips
- Routine podiatry (12 visits per year)
- Worldwide emergency and urgent coverage ($50,000 annual maximum)
- Meal benefits – Two meals per day up to 14 days following discharge from an inpatient hospital or skilled nursing facility
- Fitness benefit– Members are covered for a basic fitness membership at a participating fitness facility or an in-home fitness program
San Diego County
- Vision ($100 eyewear allowance every two years)
- Non-medical transportation – Use of taxi, standard passenger vehicle or minivan to get medically necessary services. Unlimited round trips
- Fitness benefit– Members are covered for a basic fitness membership at a participating fitness facility or an in-home fitness program
Cal MediConnect formulary
On January 1, 2021, some drugs will no longer be covered on our Cal MediConnect formulary. To assist our providers, we have included the list below 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 our website on the Coverage Determinations and Redeterminations for Drugs page on the Health Net Mediare Programs website 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 |
|---|---|
Ajovy | Aimovig, Emgality |
Esomeprazole Magnesium Susp Pack | Esomeprazole Caps, |
Humalog Mix, Humalog Mix Kwikpen | Novolog Mix 70/30, |
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 |
Humulin N, Humulin N Kwikpen | Novolin N INJ U-100, Novolin N Flexpen |
Humulin R | Novolin R, Novolin R Flexpen |
Lantus, Lantus Solostar | Basaglar, Levemir, Tresiba |
Lokelma Susp Pack | Sodium Polystyrene Oral Sulfonate Susp, Sodium Polystyrene Sulfonate Powder |
Toujeo Solostar, Toujeo Max Solostar | Basaglar, Levemir, Tresiba |
Travatan Z | Travoprost 0.004%, Latanoprost Sol 0.005%, Lumigan Sol 0.01%, Bimatoprost 0.03% |
Tudorza Pressair | Spiriva |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
| Line of Business | Telephone Number | Email Address |
|---|---|---|
| Cal Mediconnect – Los Angeles County | 1-855-464-3571 | provider_services@healthnet.com |
| Cal Mediconnect – San Diego County | 1-855-464-3572 | provider_services@healthnet.com |