21-846m 2022 Plan Codes, Supplemental Benefits and Cal MediConnect Formulary
Date: 11/30/21
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, 2022.
County | CMS1 Contract ID | 2022 Plan code | 2021 Plan Code |
|---|---|---|---|
Los Angeles | H3237-001 | J97 | HF0 (h-f-zero) |
San Diego | H3237-002 | J98 | HF1 |
1CMS – Centers for Medicare & Medicaid Services
Supplemental benefits
Long term care (LTC) is a supplemental benefit for both Los Angeles and San Diego counties. There are no other supplemental benefits in 2022.
Cal MediConnect formulary
On January 1, 2022, some drugs will no longer be covered on our Cal MediConnect formulary. To assist our providers, we have included a list of the most commonly prescribed drugs being removed along with the drug’s 2022 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 2022, you will need to submit a Coverage Determination request no sooner than November 1, 2021.
Download the Drug Coverage Determination Form or you can call to request authorization.
If you have any questions, please contact Medicare Pharmacy Services at 800-867-6564.
Product Name | Formulary Alternative |
|---|---|
Spiriva® Handihaler® | AnoroTM ElliptaTM, Breo® Ellipta®, Incruse® Ellipta® |
Omega-3-acid ethyl esters | Vascepa® |
Spiriva® Respimat® | AnoraTM ElliptaTM, Breo® Ellipta®, Incruse® Ellipta® |
Proair RespiClick® | Ventolin®` HFA |
Invokana® | Farxiga®, Jardiance® |
Premarin® cream | Delestrogen®, Estradiol |
Fluoxetine HCL tablet | Fluoxetine HCL capsule |
Stiolto® Respimat® | AnoraTM ElliptaTM, Bevespi Aerosphere®, Breo® Ellipta®, Breztri Aerosphere®, Trelegy Ellipta |
Venlafaxine HCL ER | Venlafaxine HCL ER capsule |
Pradaxa® | Jantoven®, Warfarin |
Glyburide | Glipizide, Glimepiride |
Trazodone HCL tablet 300mg | Trazodone HCL tablet 150mg |
Additional Information
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center within 60 days, by phone or through the Health Net provider website as listed below.
Provider Services
provider_services@healthnet.com
Los Angeles County – 855-464-3571
San Diego County – 855-464-3572