Pharmacy Information & Formulary Changes Q2 2019
Date: 04/01/19
This update applies to Health Net commercial plans.
Outpatient Pharmaceuticals SUBMITTED Under the Medical Benefit
See the list below for all HCPCS codes affected by changes as of 04/01/2019. “New” indicates new requirements; “Existing” indicates current requirements; “Step Therapy” indicates step therapy requirements added to existing criteria.
Newly approved medications may require prior authorization.
CHANGES, EFFECTIVE APRIL 1, 2019
Brand (Generic Name) | HCPC Code | Commercial (EPO, POS, PPO, Community Care) |
|---|---|---|
Adasuve® (loxapine for inhalation, 1 mg) | J2062 | New |
Afstyla® (antihemophilic factor recombinant) | J7210 | New |
Aliqopa™ (copanlisib) | J9057 | New |
Aristada Initio® (aripiprazole lauroxil) | C9035 | New |
Bavencio® (avelumab) | J9023 | New |
Besponsa® (inotuzumab ozogamicin) | J9229 | New |
Cuvitru (immune globulin injection 100mg) | J1555 | New |
Durolane® (hyaluronic acid) | J7318 | New J code |
Fibryga® (fibrinogen) | J7177 | New |
Haegarda® (C-1 esterase inhibitor)** | J0599** | New J code |
Hemlibra™ (emicizumab-kxwh)** | J7170** | New J code |
hydroxyprogesterone caproate injection | J1729 | New |
Ilumya™ (tildrakizumab) | J3245 | New |
Imfinzi® (durvalumab) | J9173 | New |
Ixifi (infliximab-qbtx) | Q5109 | New |
Kovaltry® (antihemophilic factor, recombinant) | J7211 | New |
Lartruvo™ (olaratumab) | J9285 | New |
Makena® (hydroxyprogesterone caproate) | J1726 | New |
Mvasi™ (bevacizumab-awwb) | Q5107 | New |
Mylotarg™(gemtuzumab ozogamicin) | J9203 | New |
Ocrevus® (ocrelizumab) | J2350 | New J code |
Poteligeo® (mogamulizumab-kpkc) | C9038 | New |
Rebinyn® (glycopegylated Factor IX) | J7203 | New |
Rituxan® (rituximab) (non-oncology only) | J9312 | New J code |
Sensipar® (ESRD on dialysis) | J0604 | New |
Tecentriq® (atezolizumab) | J9022 | New |
Trelstar® (triptorelin ER 3.75mg) | J3316 | New |
Tremfya® (guselkumab)** | J1628** | New J code |
TriVisc® (hyaluronic acid) | J7329 | New |
Trogarzo™ (ibalizumab-uiyk) | J1746 | New |
Udenyca™ (pegfilgrastim-cbqv)** | Q5111** | New |
Unclassified Rx/biological used for ESRD on dialysis | J3591 | New |
Velcade® (bortezomib) | J9044 | New |
Vyxeos® (daunorubicin and cytarabine) | J9153 | New |
Tier 1 Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Advair Diskus® | fluticasone-salmeterol 100-50 mcg/dose, 250-50 mcg/dose, and 500-50 mcg/dose aerosol powder | Respiratory agent – corticosteroid/long-acting beta-agonist
Treatment of asthma and chronic obstructive pulmonary disease (COPD) | New generic available at Tier 1
Limited to 1 Diskus per month |
albuterol sulfate HFA authorized generics NDCs: 00093317431; 66993001968 | albuterol sulfate HFA authorized generics | Respiratory agent – short-acting beta-agonist
Treatment of bronchospasm associated with asthma and chronic obstructive pulmonary disease (COPD) | Authorized generics available at Tier 1
Limited to 2 inhalers per month |
Amicar® | aminocaproic acid 500 mg and 1000 mg tablet | Hematological agents – hemostatics Treatment of hemorrhage caused by hyperfibrinolysis | New generic available at Tier 1 |
Amrix® | cyclobenzaprine HCL ER 24HR 15mg and 30mg capsule | Musculoskeletal agents – skeletal muscle relaxant Treatment of muscle spasm associated with acute painful musculoskeletal conditions unrelated to central nervous system disease | Tier 1
Limited to 1 capsule per day
Must first try cyclobenzaprine immediate release and a muscle relaxant |
Canasa® | mesalamine 1000 mg suppository | Gastrointestinal anti-inflammatory agents – 5-aminosalicylates Treatment of mildly to moderately active ulcerative proctitis | New generic available at Tier 1 |
Elidel® | pimecrolimus 1% cream | Dermatological agents – topical anti-inflammatory agents Treatment of mild to moderate atopic dermatitis | New generic available at Tier 1 Limited to 2 grams per day |
Ranexa® | ranolazine ER 500mg and 1000mg tablet | Cardiovascular agents – antianginal Treatment of chronic angina | New generic available at Tier 1 500mg tablet is limited to 4 tablets per day |
Rapamune® | sirolimus 1mg/ml solution | Biologic response modifier – immunosuppressive For kidney transplant rejection prevention | New generic available at Tier 1 |
Renagel® | sevelamer 800 mg tablet | Renal agent – phosphate binding agent Treatment of hyperphosphatemia | New generic available at Tier 1 Prior authorization required |
Sabril® | vigabatrin 500 mg tablet | Neurological agents – anticonvulsant Adjunctive treatment of refractory complex partial seizures and treatment of infantile spasms | New generic available at Tier 1 |
Sensipar® | cinacalcet HCL tablet | Hormone modifier – parathyroid agent Treatment of hypercalcemia in patients with parathyroid carcinoma and treatment of hyperparathyroidism | New generic available at Tier 1 |
Solodyn® | minocycline HCL ER 55mg, 80 mg and 105 mg tablet | Antiinfective agents – tetracycline Treatment of non-nodular moderate to severe acne vulgaris | New generic available at Tier 1 |
Suboxone® | buprenorphine-naloxone 2-0.5 mg, 4-1 mg, 8-2 mg, 12-3 mg film strip | Substance abuse agent – mixed opiate agonist/antagonist Treatment of opiate agonist dependence | New generic available at Tier 1 Prior authorization required for (WA EDL and WA ADL) Prior authorization required after first 30 days (OR EDL, OR ADL) |
Zovirax® cream | acyclovir 5% cream | Antiinfective agent – topical antivirals
Treatment of herpes labialis (i.e. cold sores) or herpes fibrilis caused by herpes simplex virus
| New generic available at Tier 1 |
Tier 2 Additions and Changes – no changes for April 1, 2019
Tier 3 Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Delstrigo™ | doravirine-lamivudine-tenofovir disoproxil fumarate tablet | Antiinfective agents – anti-retroviral non-nucleoside reverse transcriptase inhibitor (NNRTI)/anti-retroviral nucleoside reverse transcriptase inhibitor (NRTI)
Treatment of human immunodeficiency virus (HIV) infection | Tier 3
Step Therapy - must try Symfi |
Generic Vytorin® | generic ezetimibe-simvastatin tablet | Antilipemics – cholesterol absorption inhibitor/HMG-CoA reductase Inhibitor
Treatment of hypercholesterolemia or mixed hyperlipoproteinemia | Tier 3
Removed Prior Authorization and Step Therapy on generic Vytorin |
Lokelma™ | sodium zirconium cyclosilicate powder for suspension | Potassium binder
Treatment of hyperkalemia
| Tier 3
Generic Kayexalate preferred |
Moviprep® | PEG 3350-KCL-NA Sulfate-NA Ascorbate-C powder for solution | Gastrointestinal agents – laxative
Used as a bowel evacuant to clean the colon prior to colonoscopy (bowel preparation) | Tier 3* (OR EDL only)
Tier PV (WA EDL, ADL)
Prior authorization added |
Plenvu® | PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic Acid powder for solution | Gastrointestinal agents – laxative
Used as a bowel evacuant to clean the colon prior to colonoscopy (bowel preparation) | Tier 3* (OR EDL only)
Tier PV (WA EDL, ADL)
Prior authorization required |
Specialty Tier and Other Additions and Changes
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Copiktra™ | duvelisib capsule | Biologic response modifiers – signal transduction inhibitors
For the treatment of chronic lymphocytic leukemia (CLL), small lymphocytic lymphoma (SLL) and Non-Hodgkin’s lymphoma (NHL) | Tier AC
Added prior authorization |
Doptelet® | avatrombopag maleate tablet | Hematological agents – thrombopoietin receptor agonist
Treatment of thrombocytopenia in patients with chronic liver disease who are scheduled to undergo a procedure | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required |
Epidiolex® | cannabidiol solution | Neurological agents – anticonvulsant
Treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required |
Galafold™ | migalastat capsule | Metabolic agent – alpha-galactosidase A agent
Treatment of Fabry disease in adults with an amendable galactosidase alpha gene (GLA) variant | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required
Limited to 1 capsule every other day |
Kapspargo™ | metoprolol succinate sprinkle | Antihypertensive agent/antiarrhythmic– beta-blockers
Treatment of chronic stable angina, hypertension, and heart failure
| NF
Generic metoprolol succinate tablets preferred |
Nuplazid® | pimavanserin tartrate capsule | Atypical antipsychotics
Treatment of hallucinations and delusions associated with Parkinson’s disease psychosis | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required
Added limit of 1 capsule per day |
Mulpleta® | lusutrombopag maleate tablet | Hematological Agents – thrombopoietin receptor agonist
Treatment of thrombocytopenia in patients with chronic hepatic disease who are scheduled to undergo a procedure | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required |
Palynziq™ | pegvaliase-pqpz solution for injection | Metabolic enzyme
Treatment of phenylketonuria (PKU) | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required |
Perseris™ | risperidone suspension for injection kit | Atypical antipsychotics
Treatment of schizophrenia | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required |
Proair® HFA | albuterol sulfate HFA inhalation aerosol | Respiratory agent – short-acting beta-agonist
Treatment and prevention of acute bronchospasm (e.g. asthma) | Changed to NF
Generic albuterol HFA preferred |
Proventil® HFA | albuterol sulfate HFA inhalation aerosol | Respiratory agents – short-acting beta-agonist
Treatment and prevention of acute bronchospasm (e.g. asthma) | Changed to NF
Generic albuterol HFA preferred |
Qbrexza™ | glycopyrronium tosylate topical cloth | Dermatological agents
Treatment of hyperhidrosis | NF
|
Siklos® | hydroxyurea tablet | Antineoplastic agents – antimetabolite
Treatment of sickle cell disease (to reduce the frequency of painful crises and to reduce the need for blood transfusions in patients with recurrent moderate to severe painful crises) | Tier SP (EDL) Tier 3 (ADL)
Prior authorization required
Must try generic hydroxyurea |
Ventolin® HFA | albuterol sulfate HFA inhalation aerosol | Respiratory agents – short-acting beta-agonist
Treatment and prevention of acute bronchospasm (e.g. asthma) | Changed to NF
Generic albuterol HFA preferred |
Xepi™ | ozenoxacin 1% topical cream | Topical antiinfective
Treatment of impetigo | NF
Limit of 1 GM per day.
Generic mupirocin 2% topical preferred |
Xofluza™ | baloxavir marboxil tablet | Antiinfective agents- antivirals
Treatment of influenza A virus infection or influenza B virus infection | NF
Limit of #2 tablets per fill
Generic Tamiflu preferred |
ZTlido™ | lidocaine 1.8% transdermal patch | Topical anesthetics
Treatment of pain associated with postherpetic neuralgia
| NF
Added limit of 3 patches per day |
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
PV- Preventive Benefit
SP – Specialty
AC – Anti-cancer
Step Therapy – Prior authorization is required if Step Therapy is not met.
Please be sure to visit the Pharmacy Resources page at healthnetoregon.com/for-providers/resources/PharmacyResources to view the most current version of our drug lists.
Additional information
For questions regarding the information contained in this update, please contact the Health Net Pharmacy Department at 1-888-802-7001.