Formulary alternatives and restrictions for non-covered drugs
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This document lists common drugs that are not covered on the Health Net formulary and suggests covered alternative drugs, plus formulary restrictions such as prior authorization (PA) and quantity limits (QL); it is intended for providers and pharmacists applying the Health Net formulary.
No material clinical or coverage changes in this revision.
Formulary Alternatives and Coverage Rules
Formulary alternatives
Formulary guidance and coverage stance for listed non-formulary drugs and their suggested alternatives
Providers should consider the suggested alternatives; the list is not exhaustive and alternatives are suggestions only.
Prior authorization and quantity limits
Restrictions applied to certain drugs
Check the Plan's drug list for exact prior authorization criteria and quantity limits; failure to obtain required PA may result in denial.
This document is a formulary crosswalk that lists common brand drugs that are not covered on the Health Net formulary and provides suggested, covered alternatives where available. The list also indicates where formulary restrictions apply, including prior authorization (PA) and quantity limits (QL). It is intended to guide prescribing and pharmacy decisions but does not guarantee coverage of a non‑formulary drug without appropriate authorization and documentation.
Providers and pharmacists should use the suggested alternatives to select formulary medications when clinically appropriate, or to prepare supporting documentation if a non‑formulary agent is clinically necessary. For specific PA rules, QL amounts, or to confirm current coverage status, refer to the Plan drug list and PA criteria, since the formulary and restrictions may change.
Required Actions for Prescribers and Pharmacists
Obtain prior authorization for listed non‑formulary drugs
Certain non-formulary drugs listed in this crosswalk require prior authorization (PA) before the Plan will cover them. Examples called out in the document include Repatha®, Forteo®, Procrit® and Xeljanz® (and Xeljanz XR®). When PA is required, the provider must submit the Plan’s prior authorization request and supporting documentation to obtain coverage.
- Repatha® — Formulary restriction: PA (see list)
- Forteo® — Formulary restriction: PA and QL (PA required for coverage)
- Procrit® — Formulary restriction: PA
- Xeljanz® / Xeljanz XR® — Formulary restrictions: PA and QL
Preferred formulary alternatives imply step therapy
The table lists covered alternatives for many non‑formulary products, indicating the Plan prefers trial of formulary alternatives before the non‑formulary agent (implied step therapy). Providers should consider prescribing the listed preferred alternatives (e.g., Semglee® or Lantus® for Insulin Glargine‑yfgn; Mounjaro® or Ozempic® for Victoza®) prior to requesting coverage for the non‑formulary brand.
- Insulin Glargine‑yfgn — preferred alternatives: Semglee®, Lantus®
- Victoza® — preferred alternatives: Mounjaro®, Ozempic®
- Advair Diskus® — formulary alternatives listed (Fluticasone‑Salmeterol Diskus**, Breyna®, Breo Ellipta®, Advair HFA®)
Verify formulary coverage and document medical necessity
Check the Plan’s current formulary (drug list) for coverage status and any PA or quantity limit (QL) restrictions before prescribing. For PA requests, include documentation that supports medical necessity to substantiate the request.
- Use the Plan’s drug list for a comprehensive, up‑to‑date listing of covered drugs and restrictions
- Include clinical documentation when submitting PA to demonstrate medical necessity
Risk of denial if PA or quantity limits not followed
Failure to obtain required prior authorization or to adhere to noted quantity limits may result in claim denial. The document explicitly warns that requests for non‑formulary drugs may be subject to PA or QL and that failure to obtain PA when required risks denial.
- Non‑formulary requests subject to PA/QL (examples: Forteo® and Xeljanz® have PA and QL)
- Claims for drugs with PA/QL may be denied if PA is not obtained or QL exceeded
Document Purpose and Scope
Background: The crosswalk maps non‑formulary brand products to preferred formulary alternatives across common therapeutic areas (examples from the list include insulin products mapped to Semglee® or Lantus®; GLP‑1 agonists such as Victoza® mapped to Mounjaro® or Ozempic®; and inhaled controller products such as Advair Diskus® mapped to fluticasone‑salmeterol products, Breyna® or Breo Ellipta®).
The document also highlights formulary restrictions applied to certain non‑formulary drugs — for example, Repatha®, Forteo®, Procrit®, and Xeljanz®/Xeljanz XR® are noted with PA, and some entries (for example, Advair Diskus®, Forteo®, Xeljanz®) carry QL designations. These mappings and restriction flags are intended to help prescribers choose covered alternatives or assemble the necessary PA documentation.
Note: Alternative drugs are suggestions only and may not be appropriate for every patient or condition. The information is current as of May 1, 2025; providers must check the Plan drug list for the most up‑to‑date coverage and specific PA/QL requirements.
Key Terms
Preferred Alternatives and Step Therapy Implications
| Non‑formulary drug | Preferred formulary alternative(s) | Notes (PA / QL) |
|---|---|---|
| NovoLog® | None listed on formulary | Formulary restrictions noted for NovoLog® (see drug list) |
| NovoLog mix 70/30® | None listed on formulary | Formulary restrictions noted for NovoLog mix 70/30® |
| Insulin Glargine‑yfgn | Semglee®; Lantus® (alternatives also include Basaglar KwikPen®, Levemir®) | Alternatives listed on formulary |
| Victoza® | Mounjaro®; Ozempic® | Formulary alternatives listed |
| Advair Diskus® / Wixela Inhub® | Fluticasone‑Salmeterol Diskus**; Breyna®; Breo Ellipta®; Advair HFA® | QL indicated for Advair Diskus® and Wixela Inhub® |
| Symbicort® | Breyna**; Fluticasone‑Salmeterol Diskus; Breo Ellipta; Advair HFA | QL indicated for Symbicort® |
| Dulera® | Breyna; Fluticasone‑Salmeterol Diskus; Breo Ellipta; Advair HFA | QL indicated for Dulera® |
| Pulmicort Flexhaler® / Flovent® | Arnuity Ellipta® | QL indicated for Pulmicort Flexhaler® and Flovent® |
| Levalbuterol HFA | Albuterol HFA; Ventolin HFA® | QL indicated for Levalbuterol HFA |
| Gemtesa® | Fesoterodine ER; or Oxybutynin IR (listed variably) | Gemtesa® noted with QL in some entries |
| Repatha® | Praluent® | PA required for Repatha® |
Quantity Limit Notices
Biosimilar Alternatives
Lantus® and Semglee® listed as alternatives for insulin glargine‑yfgn
For insulin glargine products the crosswalk lists Lantus® and the biosimilar Semglee® (insulin glargine‑yfgn) as covered alternatives where applicable; providers should consider these listed alternatives when selecting therapy.
- Insulin Glargine‑yfgn — listed formulary alternatives include Semglee® and Lantus®.
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