CurrentHealth NetPolicy N/A

Formulary Alternative Medications — Coverage Criteria

List of non-preferred or non-formulary drugs paired with preferred formulary alternatives; intended for formulary management and prescribing guidance for Health Net providers and pharmacy staff.

Policy Summary

PayerHealth Net

PolicyFormulary Alternative Medications — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubstitute listed formulary alternatives for non-preferred or non-formulary drugs and document clinical justification for any non-formulary request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+document chunks (partial list shown)

20+drug classes with listed alternatives

includes biosimilarsmentions biosimilar alternatives

yeseach non-preferred drug has listed alternative

Coverage Criteria

Non-FDA approved drugs are excluded from coverage. The policy explicitly states that Non-FDA approved drugs are not covered, and those items listed in the formulary alternative table that are identified as non‑FDA approved should be denied as not covered under this policy.

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Provider Actions and Prescribing Guidance

Note

Formulary alternative guidance and substitution expectations

When a drug is listed as NON-PREFERRED or NON-FORMULARY, providers should select the listed formulary alternative when clinically appropriate. Formulary alternatives are provided throughout this document (examples: aripiprazole for certain antipsychotics, rabeprazole or omeprazole/pantoprazole for proton pump inhibitors, Victoza/Trulicity/Ozempic as alternatives for some GLP‑1 agents, Ziextenzo or Zarxio as biosimilar alternatives for Neulasta/Neupogen, Retacrit for Procrit/ESAs, and generic or OTC options where noted). Use of non-formulary or non-preferred agents may be discouraged and may require additional justification.

Select the listed formulary alternative when clinically appropriate; alternatives are provided by therapeutic class throughout the policy.
Common therapeutic substitution examples: Victoza, Trulicity, Ozempic recommended as alternatives to some GLP‑1 agonists (e.g., Mounjaro); aripiprazole recommended where Abilify alternatives are listed; rabeprazole/omeprazole/lansoprazole/pantoprazole for many PPI alternatives.
Biosimilar substitution suggested where available: Ziextenzo (biosimilar to Neulasta), Zarxio (biosimilar to Neupogen), Retacrit (biosimilar to Procrit).

Prior Authorization

Prior Authorization and step-therapy expectations

Use of NON-PREFERRED or NON-FORMULARY drugs may trigger prior authorization, step-therapy, or substitution requirements. When a formulary alternative is provided, step therapy is implied — prescribers should first consider the formulary alternative unless clinical justification supports the non-formulary choice.

Prior authorization is likely required for many non-formulary agents; check payer-specific PA rules before prescribing.
Step therapy is implied where a formulary alternative is recommended — the alternative should generally be tried first.
If a non-formulary agent is medically necessary, prescribers must document clinical justification in the request.

Documentation Required

Documentation required for non-formulary requests

Document clinical rationale when requesting coverage of a non-formulary or non-preferred medication. Include prior trials of formulary alternatives, reasons for failure or intolerance, and any relevant clinical data to support medical necessity.

Include prior trial details (drug, dose, duration, outcome) of formulary alternatives when submitting a non-formulary request.
State specific contraindications, allergies, or documented adverse reactions that preclude use of formulary alternatives.
Attach relevant clinical notes, lab results, or consult summaries that support the medical necessity of the non-formulary drug.

Denial Risk

Non‑FDA approved products — not covered

Some entries in the formulary list indicate non‑coverage for non–FDA‑approved drugs. Where the policy explicitly notes a product is not FDA‑approved, that agent is not covered and no substitution will be allowed; choose an approved formulary alternative instead.

Non‑FDA approved drugs listed in the formulary are not covered — select an FDA‑approved formulary alternative.
Examples in the source: several dermatologic and ophthalmic entries note 'Not a FDA approved drug - not covered.'

Definitions

inv-21: Non-FDA approved drugs — Definition: Non-FDA approved drugs are not covered.

DefinitionNon‑FDA approved drugs are not covered.

Coverage implicationNon‑FDA approved products listed as non‑preferred or non‑formulary will be denied coverage per this policy.

Provider actionPrescribers should select an FDA‑approved formulary alternative listed in the document or document clinical justification when requesting a non‑formulary agent.

inv-22: Biosimilar — Definition: A biologic designated as a biosimilar to a referenced biologic (e.g., Retacrit to Procrit).

DefinitionBiosimilar: a biologic product designated as a biosimilar to a referenced biologic (example: Retacrit as a biosimilar to Procrit).

Formulary preferenceWhere available, the policy lists biosimilars (e.g., Retacrit) as the preferred formulary alternative to the reference biologic.

Provider actionUse the listed biosimilar formulary alternative in place of the reference biologic when indicated; document clinical justification if requesting the reference biologic instead.

Formulary Alternative Recommendations

Formulary alternative recommendations

Formulary alternatives recommended for listed non-preferred or non-formulary drugs; providers should substitute the listed formulary alternative or document clinical justification when requesting a non-formulary agent.

Antivirals: XERESE → use acyclovir and hydrocortisone; XOFLUZA → use generic oseltamivir phosphate (Tamiflu).

Nasal steroids: XHANCE, ZETONNA → use fluticasone (Flonase), triamcinolone (Nasacort), or mometasone (Nasonex).

Ophthalmics: XIIDRA → use cyclosporine ophthalmic emulsion (Restasis).

Dermatologicals (acne/Topical): XOLEGEL → use ketoconazole cream; ZIANA → use clindamycin, tretinoin/benzoyl peroxide, or erythromycin/benzoyl peroxide; ZYCLARA → use imiquimod cream 5%.

Antihistamines: XYZAL → use OTC cetirizine (OTC XYZAL).

Proton pump inhibitors: ZEGERID → use omeprazole, lansoprazole, or pantoprazole.

Antihypertensives: ZESTRIL → use lisinopril tablets.

Cholesterol: ZETIA → use ezetimibe tablets.

Non-steroidal anti-inflammatory drugs (NSAIDs): ZIPSOR, ZORVOLEX → use generic diclofenac, ibuprofen, or naproxen.

Opioid analgesics: ZOHYDRO ER → use morphine CR formulations (MS Contin) or morphine beads ER; ZUBSOLV → use buprenorphine‑naloxone sublingual tablet/film.

Antidepressants: ZOLOFT → use sertraline HCl.

Sleep disorders: ZOLPIMIST → use zolpidem tartrate tablets.

Growth hormone: ZOMACTON → use Norditropin or Humatrope.

Anticonvulsants: ZONEGRAN → use zonisamide capsules.

Hematological / Antiplatelet: ZONTIVITY → use generic clopidogrel or anagrelide.

Topical anesthetics: ZTLIDO → use OTC lidocaine cream 4% or patch.

Antiemetics: ZUPLENZ → use ondansetron tablet or ODT.

Leukotriene modifiers / Respiratory: ZYFLO → use montelukast or zafirlukast.

Antipsychotics: ZYPREXA → use olanzapine tablets.

Cancer: ZYTIGA → use abiraterone acetate tablets.

Step Therapy Guidance

Non‑preferred / Non‑formulary drug	Formulary alternative (recommended)	Coverage label
Non‑preferred GLP‑1 agonists (various listed entries)	Victoza (liraglutide), Trulicity (dulaglutide), Ozempic (semaglutide)	Preferred alternatives recommended
Butrans / Bydureon / Bydureon BCise (entries grouping non‑preferred GLP‑1s)	Victoza, Trulicity, Ozempic	Preferred alternatives recommended

Non‑preferred / Non‑formulary drug	Formulary alternative (recommended)	Coverage label
MOUNJARO	Victoza (liraglutide), Trulicity (dulaglutide), Ozempic (semaglutide)	Switch to formulary GLP‑1 agents suggested

Non‑preferred / Non‑formulary drug	Formulary alternative (recommended)	Coverage label
PLAQUENIL	Hydroxychloroquine sulfate tablet	Formulary alternative recommended (implied step)
PLAVIX	Clopidogrel bisulfate tablet	Formulary alternative recommended (implied step)
PROCRIT	Retacrit (biosimilar to Procrit)	Biosimilar formulary alternative recommended

Non‑preferred / Non‑formulary drug (examples)	Formulary alternative (recommended)	Coverage label
ZORVOLEX / ZIPSOR	Use generic diclofenac, ibuprofen, or naproxen	Formulary alternatives recommended (implied step)
ZOHYDRO ER	Use morphine SR/CR formulations (e.g., MS Contin) or morphine extended‑release beads	Formulary alternatives recommended (implied step)
ZUBSOLV	Use buprenorphine‑naloxone sublingual tablet/film	Formulary alternative recommended
ZIANA	Use clindamycin, tretinoin/benzoyl peroxide, or erythromycin/benzoyl peroxide	Formulary alternatives recommended
XERESE	Use acyclovir and hydrocortisone	Formulary alternatives recommended

Biosimilar Recommendations

Billing Rule

Neulasta/Neupogen — use listed biosimilars

Ziextenzo is listed as the biosimilar formulary alternative to Neulasta and Zarxio is listed as the biosimilar formulary alternative to Neupogen; providers should use these listed biosimilars as the formulary-preferred options.

Use Ziextenzo for Neulasta.
Use Zarxio for Neupogen.

Billing Rule

Procrit — use Retacrit

Retacrit is identified as the formulary biosimilar alternative to Procrit; use of Retacrit is the listed formulary preference for erythropoiesis-stimulating agents.

Use Retacrit (biosimilar to Procrit) as the formulary alternative.

Billing Rule

Humira — use Humira or Amjevita (biosimilar) or Enbrel

For certain autoimmune indications the policy lists Humira and its biosimilar Amjevita (or Enbrel) as formulary alternatives; providers should select these formulary agents where indicated.

Use Humira or Amjevita (biosimilar to Humira) or Enbrel as the formulary alternative for listed autoimmune agents.

Billing Rule

Procrit — Retacrit listed as preferred biosimilar

Procrit is listed multiple times with Retacrit noted as the preferred biosimilar/formulary alternative; follow the listed biosimilar preference when prescribing erythropoiesis-stimulating therapy.

Retacrit is identified as the preferred biosimilar alternative to Procrit.

OpenPayer

Formulary Alternative Medications — Coverage Criteria

Coverage Criteria

Provider Actions and Prescribing Guidance

Background

Definitions

Formulary Alternative Recommendations

Step Therapy Guidance

Biosimilar Recommendations