Pharmacy Information & Formulary Changes Q1 2019
Date: 12/21/18
Health Net Oregon 19-009
2019 MAC POLICY CHANGES
Effective January 1, 2019, there will be changes to the MAC (Maximum Allowable Charge) policies offered for Oregon Small and Large Group. Oregon Small Group products will only offer MAC A policies. Oregon Large Group products will now offer both No MAC and MAC A. This change does not apply to Washington Small Group or Large Group. Washington Small and Large Group will continue to offer No MAC for 2019.
MAC A will enforce that the member receives a brand name medication when there is a generic available. If the member choses to fill a brand name product, the member will pay the applicable copayment of the brand drug PLUS the difference between the generic and brand cost.
Offering MAC A enables us to more effectively manage healthcare costs. If a member has a medically necessary need for the higher cost brand drug and cannot take the generic equivalent, providers can submit a Prior Authorization request to the Health Net Pharmacy team to request the brand name drug to be dispensed without applying the penalty (difference in cost between generic and brand drug). The prior authorization must request brand name and request an exception to the penalty or to the MAC A policy. If prior authorization is approved, applicable tier cost-shares will apply for the tier level the brand name drug is assigned to.
Maximum Allowable Charge (MAC) Policy | Definition |
|---|---|
No MAC | Brand name drugs with generic equivalents available are subject to Tier 3 copayment/coinsurance as soon as generic is available |
MAC A | Member must pay the difference between the generic and brand cost plus applicable copayment/coinsurance if a brand is requested. |
MAC B | Same as MAC A except if the Physician writes “dispense as written (DAW)” on the script, member is not responsible for the difference in cost between brand and generic. |
MAC U | Brand drugs with a generic equivalent available are not covered without Prior Authorization and Medical Necessity |
FORMULARY REMOVAL OF BRAND DRUGS WITH GENERIC AVAILABLE
Certain brand drugs with a generic available (“O” drug (originator drug)) will be removed from the formulary effective January 1, 2019. If the member continues to use the brand “O” drug, they will be responsible for the full cost of the medication. If the member has a medically necessary need for the “O” drug, providers can submit a prior authorization request to the Health Net Pharmacy team.
AVAILABLE SEATS ON THE PHARMACY AND THERAPEUTICS COMMITTEE
Seats are open on the combined Trillium Community Health Plan and Health Net of Oregon Pharmacy and Therapeutics (P&T) Committee. We are looking for community-based practitioners representing various clinical specialties who adequately represent the membership of our health plans. If you are interested in learning more or attending a quarterly meeting please contact Susan Van Horn via email at: Susan.E.VanHorn@TrilliumCHP.com. Meetings are held once a quarter and are comprised of a remote review of clinical drug information and coverage guidelines, electronic vote and committee meetings. Individuals who are selected to join by the committee are eligible to receive an honorarium to compensate them for the time spent reviewing materials and attending meetings.
Outpatient Pharmaceuticals SUBMITTED Under the Medical Benefit
See the list below for all HCPCS codes affected by changes as of January 1, 2019. “New” indicates new requirements, “Existing” indicates current requirements, and “Step Therapy” indicates step therapy requirements added to existing criteria.
For Health Net Health Plan of Oregon, Inc. commercial, newly approved medications may require prior authorization.
Additional Information
For additional information regarding changes to the Health Net formularies, contact Health Net by telephone at 1-888-802-7001.For the most current version of the formularies, visit the Health Net provider website at https://www.healthnetoregon.com/providers/resources/PharmacyResources.html.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by telephone at 1-888-802-7001.
Changes, Effective January 1, 2019
Brand (Generic Name) | HCPC Code | Commercial (EPO, POS, PPO, Community Care) |
|---|---|---|
Actemra (tocilizumab) | J3262 | Existing |
Aranesp (darbepoetin) | J0881/J0882 | Existing** |
Botox (onabotulinumtoxin a) | J0585 | Existing |
Cimzia (certolizumab pegol) | J0717 | Existing |
Epogen, Procrit (epoetin alfa) | J0885 | Existing** |
Exondys 51 (eteplirsen) | J1428 | Existing |
Eylea (aflibercept) | J0178 | Existing |
Acthar HP (corticotropin inj gel) | J0800 | Existing |
Kymriah (tisagenlecleucel) | Q2040 | Existing |
Lucentis (ranibizumab) | J2778 | Existing |
Macugen (pegaptanib) | J2503 | Existing |
Mircera (methoxy polyethylene glycol epoetin beta) | J0887 | Existing |
Ocrevus (ocrelizumab) | J2350 | Existing |
Remicade (infliximab) | J1745 | Existing |
Rituxan Hycela (rituximab-hyaluronidase) | J9467/C9467 | Existing |
Rituxan (rituximab) | J9310 | Existing (non-oncology only) |
Tysabri (natalizumab) | J2323 | Existing |
Visudyne (verteporfin) | J3396 | Existing |
Yescarta (axicabtagene ciloleucel) | Q2041 | Existing |
Neulasta (pegfilgrastim) | J2505 | Existing** |
Crysvita (burosumab-twza) | C9399/J3590 | New |
Brand (Generic Name) | HCPC Code | Commercial (EPO, POS, PPO, Community Care) |
Elaprase (idursulfase) | J1743 | New |
Mepsevii (vestronidase alfa-vjbk) | J3590 | New |
Vimizim (elosulfase alfa) | J1322 | New |
Fasenra (benralizumab) | J3590 | New |
Trogarzo (Ibalizumab-uiyk) | J3590 | New |
**Self injectables, when used as chemotherapy adjunct, do not require prior authorization.
Pharmaceuticals COVERED UNDER THE PHARMACY BENEFIT
Tier 1 Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
vancomycin | vancomycin oral capsules | Antiinfective Agent - glycopeptide antibiotic Treatment of various susceptible bacterial infections. | Generic available at Tier 1 (EDL only) Prior authorization required |
Tier 2 Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Atripla® | efavirenz-emtricitabine-tenofovir disoproxil fumarate tablet | Antiinfective agent - antiviral combination Treatment of human immunodeficiency (HIV) virus. | Tier 2 Step therapy - must try Symfi. |
Biktarvy® | Bictegravir-emtricitabine-tenofovir alafenamide fumarate tablet | Antiinfective agent - antiviral combination Treatment of human immunodeficiency (HIV) virus. | Tier 2 |
Cimduo™ | lamivudine-tenofovir disoproxil fumarate tablet | Antiinfective agent - antiviral combination Treatment of human immunodeficiency (HIV) virus. | Tier 2 |
Complera® | emtricitabine-rilpivirine-tenofovir disoproxil fumarate tablet | Antiinfective agent - antiviral combination Treatment of human immunodeficiency (HIV) virus. | Tier 2 Step therapy - must try Symfi. |
Odefsey® | emtricitabine-rilpivirine-tenofovir alafenamide fumarate tablet | Antiinfective agent - antiviral combination Treatment of human immunodeficiency (HIV) virus. | Tier 2 Step therapy - must try Symfi. |
Symfi/Symfi Lo™ | efavirenz-lamivudine-tenofovir disoproxil fumarate tablet | Antiinfective agent - antiviral combination Treatment of human immunodeficiency (HIV) virus. | Tier 2 |
Tier 3 Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Lucemyra™ | lofexidine HCL tablet | Substance abuse agents- withdrawal agents Treatment of opiate agonist withdrawal symptoms to facilitate abrupt opiate discontinuation. | Tier 3 (OR EDL/ADL ONLY) Added limit of #224 tablets per 14 day supply. PA required for more than a 30 day supply per year. |
Osmolex ER™ | amantadine extended-release tablet | Neurological agents - antiparkinsonian agent Treatment of Parkinson’s disease and for the treatment of drug-induced extrapyramidal reactions. | Tier 3 Prior authorization required |
Siklos® | hydroxyurea tablet | Antineoplastic agent – antimetabolite Indicated to reduce the frequency of painful crises and to reduce the need for blood transfusions in pediatric patients, 2 years of age and older, with sickle cell anemia with recurrent moderate to severe painful crises. | Tier 3 Added age limit of less than 19 years. |
Stimate® | desmopressin nasal spray | Hematological agents – hemostatics Indicated for the management of spontaneous bleeding or trauma-induced hemorrhage or for bleeding prophylaxis in patients with hemophilia A or mild to moderate von Willebrand’s disease type 1. | Tier 3 (EDL only) Prior authorization added |
Symtuza™ | darunavir-cobic-emtricitab-tenofov AF Tablet | Antiviral agents – HIV-1 Indicated as a complete regimen for treatment of HIV-1 infection in adults who have no prior treatment history or who are virologically suppressed on a stable regimen for at least 6 months and have no known substitutions assoc with resistance to darunavir or tenofovir. | Tier 3 Step therapy - must try Symfi |
Specialty Tier and Other Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Aimovig™ | erenumab solution for injection | Neurological agents – anti-migraine agents Indicated for preventive treatment of migraine in adults. | Tier SP (EDL) Tier 3 (ADL) Prior authorization required |
Braftovi™ | envorafenib capsule | Antineoplastic agents – kinase inhibitor For use in combination with binimetinib, for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation, as detected by an FDA-approved test. | Tier AC Prior authorization required |
Ilumya™ | tildrakizumab-asmn solution for injection | Biologic response modifier – interleukin inhibitor Treatment of moderate to severe plaque psoriasis in patients who are candidates for systemic therapy or phototherapy. | Tier SP (EDL) Tier 3 (ADL) Prior authorization required |
Jynarque® | tolvaptan tablet | Renal agents - selective vasopressin V2-receptor antagonist Treatment of autosomal dominant polycystic kidney disease (ADPKD) to slow kidney function decline in patients at risk of developing rapidly progressing ADPKD. | Tier SP (EDL) Tier 3 (ADL) Prior authorization required |
Kevzara® Auto-injector | sarilumab solution for injection | Disease Modifying Antirheumatic Drugs (DMARDs) – interleukin inhibitors Treatment of moderate to severe rheumatoid arthritis inpatients who have had an inadequate response or intolerance to one or more disease modifying antirheumatic drugs. | Tier SP (EDL) Tier 3 (ADL) Prior authorization required |
Mektovi® | binimetinib tablet | Antineoplastic agents – MEK inhibitor For use in combination with encorafenib, for the treatment of patients with unresectable or metastatic melanoma with a BRAF V600E or V600K mutation, as detected by an FDA-approved test. | Tier AC Prior authorization required |
Nuplazid® | pimavanserin tartrate tablet | Atypical antipsychotic Treatment of hallucinations and delusions associated with Parkinson’s disease psychosis. | Tier SP (EDL) Tier 3 (ADL) Prior authorization required |
Panretin® | alitretinoin 1% gel | Antineoplastic agents - topical retinoid Treatment of cutaneous lesions in patients with AIDs-related Kaposi’s sarcoma. | Tier AC (WA EDL only) Prior authorization added |
Purixan® | mercaptopurine suspension | Antineoplastic agents – purine analog Treatment of acute lymphocytic leukemia (ALL) | Tier AC (EDL only) Prior authorization added |
Talzenna™ | talazoparib capsule | Antineoplastic agents – poly (ADP-ribose) polymerase (PARP) inhibitor Treatment of deleterious or suspected deleterious germline BRCA-mutated (gBRCAm), HER2-negative locally advanced or metastatic breast cancer. | Tier AC Prior authorization added |
Tavalisse™ | fostamatinib disodium tablet | Hematological agents – hemostatics Treatment of thrombocytopenia in patients with chronic idiopathic thrombocytopenic purpura (ITP). | Tier SP (EDL) Tier 3 (ADL) Prior authorization required |
Vizimpro® | dacomitinib tablet | Antineoplastic agents – epidermal growth factor (EGFR) kinase inhibitor Treatment of non-small cell lung cancer (NSCLC). | Tier AC Prior authorization added |
1 Changes listed in the table apply to EDL and ADL unless a specific formulary is noted.
2 Tier 1*, Tier 2*, Tier 3*, PV - *These preventive medications are covered at $0 cost share if you have a Preventive Pharmacy benefit
Definitions
ADL – AonActive Drug List
EDL – Essential Rx Drug List
NF – Non Formulary
SP – Specialty
AC – Anti-cancer
Step Therapy – Prior authorization is required if Step Therapy is not met.