21-724 Medication Trend Updates and Formulary Changes - 4th Quarter 2021
Date: 10/25/21
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:
- Changes to the Health Net commercial Formulary, Medi-Cal Preferred Drug List (PDL) and Medicare Part D Formulary for the fourth quarter of 2021.
- New Buprenorphine Practice Guidelines.
- New Pharmacy Lock-In Program for the Individual Market in 2022.
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 fourth quarter of 2021.
Complete lists of the commercial Formularies, Medi-Cal PDLs and Medicare Part D Formularies are available on the Health Net provider website as listed in the right-hand column of this page.
New Buprenorphine Practice Guidelines, Expanding Access to Treatment for Opioid Use Disorder
According to the Centers for Disease Control and Prevention, as of June 2020, 13% of Americans reported starting or increasing substance use as a way of coping with stress or emotions related to COVID-19. The reported number of deaths of opioid specific overdose in California in 2020 was 5,659 (a 70% increase compared to 2019). Those with substance use disorders (SUD) are both more likely to develop COVID-19 and experience worse COVID-19 outcomes, including higher risk of hospitalization and mortality.1 The U.S. Department of Health and Human Services (HHS) published the Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder: "exempting physicians from certain certification requirements needed to prescribe buprenorphine for opioid use disorder (OUD) treatment."2 Physicians utilizing this exemption will be limited to treating no more than 30 patients with buprenorphine for opioid use disorder at any one time.
Call to Action for Health Net Providers:
- Prioritize COVID-19 vaccinations among patients with a history of SUD.
- Educate on effective Medication Assisted Treatment (MAT), especially buprenorphine treatment, per the Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines.
- Identify patients who begin showing signs of substance use disorder.
- Create opioid tapering plans for those on high doses of combined opioids.
- Co-prescribe naloxone to patients to reduce risk of overdose/death.
1 (Wang, Q., et al., Molecular Psychiatry, 2020)
2 Department of Health and Human Services
New Pharmacy Lock-In Program in 2022 for the Individual Market Only
Beginning in 2022, Health Net’s pharmacy services team, together with Medical Management, will review a member's medication usage and history, and using the criteria below, may enroll members in the Pharmacy Lock-In Program.
A member enrolled in the Pharmacy Lock-In Program is limited to using one specific retail pharmacy for a 12-month period to obtain all prescription drugs, with the exception of prescription drugs dispensed in conjunction with emergency care, 90-day supplies of maintenance drugs through the mail-order program and specialty drugs obtained through the specialty pharmacy vendor.
A member also has the right to request a review of the decision to place them in a lock-in program upon receiving the notification letter.
Criteria:
A member needs to meet one of the following criteria to be considered for the Pharmacy Lock-In Program:
- Prescriptions written on a stolen, forged or altered prescription blank issued by a licensed prescriber, which led to a member conviction within the past 24 months. Generally, this is reported by the Provider to the plan.
- Member has diagnosis in the past 24 months of drug poisoning, drug or alcohol abuse, a suicide attempt or suicidal ideations and has filled prescription medications in two or more pharmacies in the last 180 days. Illicit drug abuse or dependency may be counted as well.
- Referrals from the provider reporting suspected abuse or the prescriber is specifically requesting the lock-in due to alleged abuse. Such provider request will be clearly documented in clinical database.
- Member had two or more violations of a pain contract with the same or different prescriber in a 24-month period.
OR
A member needs to meet two or more of the following criteria to be considered for the Pharmacy Lock-In Program:
- Prescribed medications do not correlate with the member’s medical condition, as identified by his/her PCP, or ICD-10 code from encounter data.
- Member has filled controlled prescriptions at three or more pharmacies per any 90-day period. Pharmacies are distinct and do not share a database. Example: Two CVS stores would count as one pharmacy, but a Walgreens and a CVS store would count as two pharmacies.
- Member receives three or more controlled substance medications from two or more doctors in any 90-day period. The doctors are not affiliated with the same practice.
- Member receives overlapping or duplicative prescription medications that may result in an adverse event from two or more providers or pharmacies lasting 6 weeks or longer in any 90-day period.
- Member has been seen in a hospital emergency room two or more times in any 90-day period with excessive non-emergent claims. Example: toothache, back pain, contusion, unspecified pain, etc.
- Member has a high Morphine Equivalency Dose (MED) of greater than or equal to 90 morphine milligram equivalents (MME) in any 90-day period. If there are any cash claims known and validated, these can be factored into the total MME calculation.
- Member has medication claims in profile of high abuse potential such as combinations of opiates, muscle relaxers, stimulants, and benzodiazepines (also known as Holy Trinity or Houston Cocktail) in any 90-day period.
For more information regarding changes to the Health Net commercial Formulary, Health Net Medi-Cal PDL or Medicare Part D Formulary, contact the proper pharmacy phone numbers listed below:
Products | Contact Number | Fax Number |
|---|---|---|
Commercial (HMO, POS, HSP, PPO & EPO) | 800-548-5524, option #3 | 866-399-0929 |
Cal MediConnect Medicare Advantage | 800-867-6564 | 800-977-8226 |
Medi-Cal | 800-867-6564 | 866-399-0929 (Pharmacy Prior Authorization) 833-953-3436 (Medical Pharmacy Prior Authorization) |
MEDICATION | Status | Health Net Formulary Alternative(s) | COMMENTS | ||||
|---|---|---|---|---|---|---|---|
Commercial Tier 3 plan (Tier 4 plan) | Medicare Part D (6-Tier preferred)* | Medi-Cal | Commercial | Medicare | Medi-Cal | ||
| Injectable preparations | |||||||
Abecma® (idecabtagene vicleucel) for IV infusion | Medical benefit** | Medical benefit** | Medical benefit** |
|
|
| The first chimeric antigen receptor (CAR) T cell therapy for relapsed/refractory multiple myleloma after four or more prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-CD38 monoclonal antibody. |
Aduhelm™ (aducanumab) for IV infusion | Medical benefit** | Medical benefit** | Medical benefit** |
|
|
| Aduhelm is an amyloid beta-directed antibody indicated for the treatment of Alzheimer’s disease. Treatment with Aduhelm should be initiated in patients with mild cognitive impairment or mild dementia stage of disease, the population in which treatment was initiated in clinical trials. There are no safety or effectiveness data on initiating treatment at earlier or later stages of the disease than were studied |
Nulibry™ (fosdenopterin) for IV infusion | Medical benefit** | Medical benefit** | Medical benefit** |
|
|
| A cyclic pyranopterin monophosphate (cPMP) substrate replacement therapy and the first treatment for Molybdenum Cofactor Deficiency (MoCD), type A only. |
*Medicare Part D = Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO C-SNP), Health Net Ruby (HMO), Health Net Ruby Select (HMO), Health Net Sapphire (HMO), Health Net Violet 1 (PPO), Health Net Violet 2 (PPO), Health Net Violet 3 (PPO), Health Net Violet 4 (PPO).
**Prior authorization (PA) is required to verify member eligibility and that the member satisfies clinical protocols to ensure appropriate use of the medication.
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days, by phone or through the Health Net provider website as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 |
| |
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 |
Cal MediConnect – Los Angeles County | 1-855-464-3571 | N/A | provider_services@healthnet.com |
Cal MediConnect – San Diego County | 1-855-464-3572 | N/A |