Pharmacy Drug List Changes 3rd Quarter 2020
Date: 07/01/20
Outpatient Pharmaceuticals Submitted Under the Medical Benefit
See the list below for all HCPCS codes affected by changes as of 07/01/2020. “New” indicates new requirements, “Existing” indicates current requirements, “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.
(For Medicare please refer to the Health Net Pre-Authorization check tool on our website at https://or.healthnetadvantage.com/for-providers/medicare-pre-auth.html. Simply enter the CPT code and the pre-authorization check tool will advise you whether the service requires prior authorization.)
Brand (Generic Name) | HCPC Code | Commercial (EPO, POS, PPO, Community Care) |
|---|---|---|
Third Quarter 2020 Changes | ||
Adakveo® (crizanlizumab-tmca) | C9053/C9399/J3490/J3590 | New |
Bynfezia Pen™ (octreotide acetate) | J2354 | New |
Darzalex Faspro™ (daratumumab-hyaluroidase-fihj) | J3590 | New |
Durysta™ (bimatoprost intracameral implant) | J3490/C9399 | New |
Eylea® (afibercept) | Q0178 | Updated |
Givlaari® (givosiran) | C9056 | New |
Jelmyto™ (mitomycin for pyelocalcaeal solution) | J3490/J999/C9399 | New |
Ontruzant® (trastuzumab-dttb) | Q5112 | New |
Romidepsin (romidepsin) | J9315 | New |
Retacrit® (epoetin alfa-epbx) | Q5106 | Updated |
Rituxan® (rituximab) | J9312 | Updated |
Ruxience® (rituximab-pvvr) | J999 | Updated |
Sarclisa® (isatuximab-irfc) | C9399/J3490/J3590/J9999 | New |
Truxima® (rituximab-abbs) | Q5115 | Updated |
Zarxio® (filgrastim-sndz) | Q5101 | Updated |
Ziextenzo® (pegfilgrastim-bmez)** | C9058 | New |
**Self injectables, when used as chemotherapy adjunct, do not require prior authorization.
PHARMACEUTICALS COVERED UNDER THE PHARMACY BENEFIT
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Tier 1 Additions and Changes | |||
Tier 2 Additions and Changes | |||
Cimduo® | Lamivudine-Tenofovir Disoproxil Fumarate | Combination HIV-1 reverse transcriptase inhibitors. For use in combination with other antiretroviral medications to treat human immunodeficiency virus (HIV) infection | Step Therapy |
Descovy® | Lamivudine-Tenofovir Disoproxil Fumarate | Combination HIV-1 reverse transcriptase inhibitors. Proposed for pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 infection among individuals who are HIV-negative and at risk for HIV | Prior Authorization |
Xtampza ER® | Oxycodone | Extended-release opioid analgesic
Treatment of severe chronic pain in patients requiring a long-term daily around-the-clock opioid analgesic | Tier 2 and Prior Authorization |
Tier 3 Additions and Changes | |||
Caplyta™ | Lumateperone | An antipsychotic
Treatment of Schizophrenia | Tier 3 and Prior Authorization Quantity limit of 1 tablet per day |
Hysingla ER® | Hydrocodone Bitartrate | Extended-release opioid analgesic
Treatment of severe chronic pain in patients requiring a long-term daily around-the-clock opioid analgesic | Tier 3 and Prior Authorization |
Secuado® | Asenapine
| An antipsychotic
Treatment of adults with schizophrenia | Tier 3 and Prior authorization Quantity limit of 1 patch per day |
Skyrizi™ | Risankizumab-rzaa | An IL-23 antagonist
Treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy | Tier 3 and Prior authorization on OR ADL and OR EDL |
Oxycontin® | Oxycodone Hydrochloride | Long-acting opioid analgesic
Treatment of severe chronic pain in patients requiring a long-term daily around-the-clock opioid analgesic | Tier 3 and Prior Authorization |
Rinvoq™ | Upadacitinib | JAK inhibitor
Treatment of adults with moderately to severely active rheumatoid arthritis who have had an inadequate response to intolerance to methotrexate | Tier 3 and Prior authorization on OR ADL
|
Valtoco® | Diazepam | An antiepileptic nasal spray
Acute treatment of intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient’s usual seizure pattern in patients with epilepsy 6 years of age and older | Tier 3 on OR ADL Quantity Limit of 10 nasal spray devices per 30 days |
Zohydro® ER | Hydrocodone | Long-acting opioid analgesic
Treatment of severe chronic pain in patients requiring a long-term daily around-the-clock opioid analgesic | Tier 3 and Prior Authorization |
Specialty Tier and Other Additions and Changes | |||
Ayvakit™ | Avapritinib | A tyrosine kinase inhibitor
Treatment of adults with unresectable or metastatic fourth-line gastrointestinal stromal tumor (GIST) harboring a platelet-derived growth factor receptor alpha (PDGFRA) exon 18 mutation, including PDGFRA D842V mutations | AC with Prior Authorization and Quantity Limit of 1 tablet per day |
Brukinsa™ | Zanubrutinib | A Bruton’s tyrosine kinase (BTK) inhibitor
Treatment of Mantle cell lymphoma, following at least one prior therapy | AC with Prior Authorization |
Jelmyto™ | mitomycin for pyelocalcaeal solution | An antibiotic with antimetabolite activity
Treatment of adult patients with low-grade upper tract urothelial cancer (LG-UTUC) | NF with prior authorization |
Retevmo™ | Selpercatinib | A kinase inhibitor
Treatment of adults with metastaic RET fusion-positive non-small cell lung cancer (NSCLC), adult and pediatric patients greater than or equal to 12 years of age with advanced or metastatic RET-mutant medullary thyroid cancer (MTC) who require systemic therapy, and adults and pediatric patients greater than or equal to 12 years of age with advanced or metastatic RET fusion-positive thyroid cancer who require systemic therapy and who are radioactive iodine-refractory | NF with prior authorization |
Reyvow™ | Lasmiditan succinate | A serotonin (5-HT) receptor agonist
Acute treatment of migraine attacks with or without aura in adults | NF with Quantity Limits of 4 tablets per month of 50 MG and 8 tablets per month of 100 MG |
Rinvoq™ | Upadacitinib | JAK inhibitor
Treatment of adults with moderately to severely active rheumatoid arthritis who have had an inadequate response to intolerance to methotrexate | Specialty Tier with prior authorization on WA EDL and OR EDL |
Skyrizi™ | Risankizumab-rzaa | An IL-23 antagonist
Treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy | Specialty Tier with prior authorization on WA EDL
|
Tabrecta™ | Capmatinib | A kinase inhibitor that targets mesenchymal-epithelial transition (MET)
Treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have a mutation that leads to mesenchymal-epithelial transition (MET) exon 14 skipping as detected by an FDA-approved test | NF with prior authorization |
Valtoco® | Diazepam | An antiepileptic nasal spray
Acute treatment of intermittent, stereotypic episodes of frequent seizure activity that are distinct from a patient’s usual seizure pattern in patients with epilepsy 6 years of age and older | Specialty on OR and WA EDL Quantity Limit of 10 nasal spray devices per 30 days |
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
3 Self injectables, when used as chemotherapy adjunct, do not require prior authorization
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 our website at www.healthnetoregon.com 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.