Provider Update: Pharmacy Drug List Changes - 1st Quarter 2020
Date: 12/27/19
Provider Update: Outpatient Pharmaceuticals Submitted Under the Medical Benefit
See the list below for all HCPCS codes affected by changes as of 01/01/2020. “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 Advantage, 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) |
|---|---|---|
Ajovy® (fremanezumab-vfrm) | J3031 | New |
Aristada® (aripiprazole lauroxil) | J1944 | New |
Aristada Initio® (aripiprazole lauroxil) | J1943 | New |
Asparlas™ (calaspargase pegol-mknl) | J9118 | New |
Elzonris™ (tagraxofusp-erzs) | J9269 | New J code |
Evenity® (romosozumab-aqqg) | J3111 | New |
Gamifant® (emapalumab-lzsg) | J9210 | New J Code |
Kanjinti™ (trastuzumab-anns) | Q5117 | New J Code |
Libtayo® (cemiplimab-rwlc) | J9119 | New J Code |
Lumoxiti™ (moxetumomab pasudotox-tdfk) | J9313 | New J Code |
Nuzyra®(omadacycline) | J0121 | New J Code |
Onpattro® (patisiran) | J0222 | New J Code |
Perseris™ (risperidone) | J2798 | New |
Poteligeo® (mogamulizumab-kpkc) | J9204 | New |
Synojoynt™ (hyaluronan or derivative) | J7331 | New J Code |
Takhzyro® (lanadelumab-flyo) | J0593 | New J Code |
Trazimera™ (trastuzumab-qyyp) | Q5116 | New |
Triluron™ (hyaluronan or derivative) | J7331 | New J Code |
Ultomiris® (ravulizumab-cwvz) | J1303 | New J Code |
Xerava™ (eravacycline) | J0122 | New |
Zemdri™ (plazomicin) | J0291 | New J Code |
Ziextenzo™ (pegfilgrastim-bmez) | J3590 | New |
Zirabev™ (bevacizumab-bvcr) | Q5118 | New J Code |
Brand Name | Generic Name | Therapeutic Category & Indication | Comments |
|---|---|---|---|
Tier 1 Additions and Changes | |||
Tier 2 Additions and Changes | |||
Dovato® | Dolutegravir/lamivudine | Combination HIV integrase inhibitor and synthetic nucleoside analogue Treatment of HIV-1 infection in virologically suppressed adults on a stable antiretroviral regimen with no treatment failure | Tier 2 |
Tresiba® | Insulin degludec | An insulin Treatment of Type 1 diabetes mellitus and Type 2 diabetes mellitus | Tier 2 |
| Tier 3 Additions and Changes | |||
Corlanor® | Ivabradine Oral Solution | Hyperpolarization-activated cyclic nucleotide-gated channel blocker Treatment of stable symptomatic heart failure due to dilated cardiomyopathy (DCM) in pediatric patients aged 6 months and older, who are in sinus rhythm with an elevated heart rate | Tier 3 Step Therapy – must try two beta blockers Added limit of #15 ML per day |
Seebri NeoHaler® | Glycopyrrolate Inhalation capsule 15.6 MCG | Anticholinergic/ antimuscarinic agent Treatment of chronic obstructive pulmonary disease | Prior Authorization Required |
Specialty Tier and Other Additions and Changes | |||
Aemcolo™ | Rifamycin sodium | Ansamycin antibacterial Treatment of traveler’s diarrhea | Added limit of #12 tablets per fill |
Bactroban 2% Cream® | Mupirocin | A topical antibiotic Treatment of impetigo | NF Added limit of #30 grams per fill |
Balversa ™ | Erdafitinib | A fibroblast growth factor receptor (FGFR) kinase inhibitor. Treatment of adult patients with locally advanced or metastatic urothelial carcinoma that has: susceptible FGFR3 or FGFR2 genetic alterations and progressed during or following at least one line of prior platinum-containing chemotherapy including within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy. | Tier AC Prior Authorization required
|
Cablivi ® | Caplacizumab-yhdp injection | A von Willebrand factor (vWF)-directed antibody fragment Treatment of adult patients with acquired thrombotic thrombocytopenic purpura (aTTP), in combination with plasma exchange and immunosuppressive therapy. | Tier SP (EDL) Tier 3 (ADL)
Prior Authorization required
|
Diacomit ® | Stiripentol | An antiepileptic Treatment of seizures associated with Dravet syndrome in patients 2 years of age and older taking clobazam; there are no clinical data to support the use of Diacomit as monotherapy in Dravet syndrome. | Tier SP (EDL) Tier 3 (ADL) Prior Authorization required
|
Duaklir Pressair® | Aclidinium Br-Formoterol Fum Aero Pow BR Act 400-12 MCG/ACT | Combination long-acting muscarinic antagonist and long-acting beta 2-adrenergic agonist Maintenance treatment of chronic obstructive pulmonary disease (COPD) | NF |
Fiasp Penfill ® | Insulin Aspart (with Niacinamide) Soln Cartridge 100 Unit/ML | Anti-hyperglycemic Treatment of Type 1 diabetes mellitus and Type 2 diabetes mellitus | NF |
Gvoke PFS™ | Glucagon | Antihypoglycemic Treatment of severe hypoglycemia in patients with diabetes ages 2 years and above | NF |
Mavenclad ® | Cladribine | A cytotoxic purine antimetabolite Treatment of relapsing forms of multiple sclerosis (MS), to include relapsing-remitting disease and active secondary progressive diease, in adults. | Tier SP (EDL) Tier 3 (ADL) Prior Authorization required |
Nayzilam ® | Midazolam Nasal | Anti-seizure medication Treatment of intermittent, stereotypic episodes of frequent seizure activity | NF |
Nourianz ™ | Istradefyline Tab 20 MG, 40 MG | An adenosine A2A receptor antagonist Treatment of Parkinson’s disease in combination with levodopa/carbidopa | NF |
Ozobax ™ | Baclofen Oral Soln 5 MG/ML | A muscle relaxant and anti-spasmotic Treatment of spasticity resulting from multiple sclerosis. | NF |
Rybelsus ® | Semaglutide Tab 14 MG, 3 MG, 7 MG | A glucagon-like peptide-1 receptor agonist Treatment of Type 2 diabetes mellitus | NF |
Tolsura® | Itraconazole | Anti-fungal Treatment of the following fungal infections in immunocompromised and non-immunocompromised adult patients: Blastomycosis, pulmonary and extrapulmonary, Histoplasmosis, including chronic cavitary pulmonary disease and disseminated, non-meningeal histoplasmosis, and Aspergillosis, pulmonary and extrapulmonary, in patients who are intolerant of or who are refractory to amphotericin B therapy | Tier SP (EDL) Tier 3 (ADL) Prior Authorization Required
|
Trikafta™ | Elexacaftor-Tezacaftor-Ivacaftor | Combined effect of elexacaftor, tezacaftor, and ivacaftor is increased quantity and function of F508del-CFTR at the cell surface, resulting in increased CFTR activity as measured by CFTR mediated chloride transport Treatment of cystic fibrosis in patients with at least one F508del mutation in the CTFR gene | Tier SP (EDL) Tier 3 (ADL) Prior Authorization Required Added limit of #3 tablets per day
|
Trinaz | Prenatal Vit W/Fe Gluconate=FA | A prenatal multi-vitamin A prescription dietary supplement for use throughout pregnancy, during the postnatal period for both lactating and non-lactating mothers, and throughout the childbearing years. | NF
|
Wakix ® | Pitolisant HCI Tab 17.8 MG, 4.45 MG 9 | A histamine-3 (H3)-receptor antagonist/inverse agonist Treatment of excessive daytime sleepiness (EPS in adult patients with narcolepsy | NF
|
Zelnorm™ | Tegaserod | Serotonin-4 (5-HT4) receptor agonist Treatment of adult women less than 65 years of age with irritable bowel syndrome with constipation (IBS-C) | NF |
Ziextenzo™ | pegfilgrastim-bmez | A colony stimulating factor To decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia | Tier SP (EDL) Tier 3 (ADL) Prior Authorization Required
|
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.
Medicare Advantage Drug List at www.or.healthnetadvantage.com
Additional information
For questions regarding the information contained in this update, please contact the Health Net Pharmacy Department at 1-888-802-7001.