22-610 Medication Trend Updates and Formulary Changes - 2nd Quarter 2022
Date: 08/04/22
This information applies to Physicians and Participating Physician Groups (PPGs)
For Medi-Cal, this information applies to Kern, Los Angeles, Riveside, Sacramento, San Bernardino, San Diego, San Joaquim, Stanislaus and Tulare counties.
Review formulary changes and medication safety issues
Stay up to date with info about:
- Pharmacy Lock-In Program.
- Changes to the Health Net Commercial Formulary and Medi-Cal medical benefit drugs for the second quarter of 2022.
Pharmacy Lock-In Program
Beginning third quarter 2022, Ambetter from Health Net plans will implement a Pharmacy Lock-In Program for members meeting specific criteria.
The Pharmacy Lock-In Program is intended to prevent members from obtaining excessive quantities of prescribed opioid drugs through multiple visits to providers, pharmacies or facilities. The Centene pharmacy team, plan pharmacists and medical management will review a member's medication usage and history and, using the Pharmacy & Therapeutics Committee-approved guidelines, may enroll members in the Pharmacy Lock-In Program.
Program elements include:
- Pharmacy claims will be audited monthly using guidelines to identify potential misuse of prescription medications.
- When a possible inappropriate use is identified, a letter summarizing the decision to use the lock-in program is sent to the member, as well as copies to the designated pharmacy and primary care provider. The lock-in period is 12 months. If the member wishes to appeal the decision to be placed in lock-in or to designate an alternate pharmacy or prescribing provider, they may submit a request to the Health Plan Appeals and Grievances Department.
- Health Plan may provide case management and education reinforcement of appropriate medication/pharmacy to lock in members.
- Provisions will be made for the member to obtain an emergency supply of medication at pharmacies other than the designated lock-in pharmacy to assure the provision of necessary medication required in an emergency (e.g., when the designated pharmacy is closed, the member cannot readily access the pharmacy, or the pharmacy does not have the required medication in inventory). Such overrides will be specific to the member’s situation, customizable per the pharmacy coordinator’s discretion.
- Note that members with cancer, malignant neoplasms, or sickle cell disease will not be included in the lock-in program.
Health Net Commercial Formulary, Medi-Cal Preferred Drug List and Medicare Part D Formulary changes
There were no Health Net Commercial Formulary or Medi-Cal medical drug benefit changes for second quarter 2022.
Pharmacy help line
For more information regarding changes to the Health Net Commercial Formulary or Health Net Medi-Cal Preferred Drug List, contact the proper pharmacy phone numbers listed below:
Product | Phone number | Fax number |
|---|---|---|
Pharmacy Benefit (Medi-Cal Rx) | 800-977-2273 | 800-869-4325 |
Medical Benefit Drugs (Medi-Cal) | 877-277-0413 | 833-953-3436 |
Commercial Pharmacy Services | 800-548-5524, option #3 | 866-399-0929 |
Medicare Pharmacy Service Center | 800-867-6564 | 800-977-8226 |
Additional information
Providers are encouraged to access Health Net’s provider portal online at provider.healthnetcalifornia.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
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 | Phone number | Email address |
|---|---|---|
EnhancedCare PPO (IFP & SBG) | 844-463-8188 | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 800-641-7761 | |
IFP (CommunityCare HMO, PPO, PureCare HSP, & PureCare One EPO) | 888-926-2164 | |
Medicare (Individual & Employer Group) | 800-929-9224 | |
Medi-Cal | 800-675-6110 | N/A |