Drug Information for Medicare
- Drug and Pharmacy Information
- Drug Transition Policy
- Prior Authorization, Step Therapy and Quantity Limits
- Find a Pharmacy
H0562_19_11585EGWEB_C_03142019
Information last updated 10-06-2015
H0562_19_11585EGWEB_C_03142019
Information last updated 10-06-2015
If a prescription drug is not covered, or there are coverage restrictions or limits on a drug, members or providers may request a coverage determination.
Members or providers can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested. An exception can be requested to:
Generally, Health Net will only approve a request for an exception if preferred alternative drugs or utilization restrictions would not be as effective in treating the member's condition and/or would cause the members to have harmful medical effects.
Some drugs require prior authorization. This means that members must receive approval from Health Net before the drug will be covered. The prior authorization process ensures members are receiving the correct drug combined with the best value for their medical condition.
To request an exception or to obtain prior authorization, members or prescribers can email, fax or mail a coverage determination request to the contact information listed below. A coverage determination can also be requested by calling Customer Service. If a request is sent by email, it must include the member's name, Health Net member ID number and telephone number, as well as the details of the request. We also require a supporting statement from the prescriber explaining why a particular drug is medically necessary for the member's condition.
Once we receive the coverage determination request, it is reviewed to determine if it meets the requirements for approval. We must make our decision regarding an exception or prior authorization request and respond no later than 72 hours (24 hours for Medi-Cal covered drugs) after we have received the prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered. If we deny the request, members can appeal our decision. Information on how to file an appeal is included with the denial notification.
If waiting up to 72 hours for a "standard" decision could seriously harm the member's health or their ability to function, members or their prescribers can ask us to make a "fast" decision. A fast decision is sometimes called an expedited coverage determination and applies only to requests for Part D drugs that members have not already received. If a request for a fast decision is received, we must make our decision and respond within 24 hours. Requests for a fast decision can be made by fax or by calling Customer Service. We will make our decision and respond to all requests as quickly as the member's health condition requires.
Prescribers: 1-800-867-6564
Calls received after hours will be handled by our automated phone system and a Health Net representative will return the call on the next business day.
To protect personal health information and privacy, please do not send emails to Health Net using a personal email account. Health Net has a Secure Messaging Center to make corresponding with us safe and efficient. To access Secure Messaging, you must be registered on HealthNet.com.
Log in to the Secure Messaging Center. Select Compose. You will be prompted to enter an email address in the To: field. Paste medicaredeterminations@healthnet.com in the To: field. Please attach any supporting or relevant documents to your secure email message.
Health Net Prior Authorization Department
PO Box 419069
Rancho Cordova, CA 95741-9069
1-800-977-8226
For more information about coverage determinations, exceptions and prior authorization, refer to the plan's coverage documents or call Customer Service. The fact that a drug is listed on the formulary does not guarantee that it will be prescribed for a particular medical condition.
Log In:
Members
Individual & Family Plan member
CA: Log in at myhealthnetca.com
AZ: Log in at ambetterhealth.com
Medicare Advantage member
Log in at membersecurelogin.com
Employer Group Plan member
All other plan members
Log In:
Providers
I need to access...
Information about Allwell, Ambetter or HNA members
Information about members in other plans
Log In:
Providers
Member information is available on provider.healthnetarizona.com.
Already have an account?
Log in now
(your username is your email address)
Note: HNA providers can log in by using their existing HNA user name (your email address) and password to access Allwell and Ambetter member information.
Need to create a new account?
Register now
Log In:
Providers
I need to access...
Information about IFP or individual Medicare Advantage members
Information about members in other plans
Log In:
Providers
Member information is available on provider.healthnetcalifornia.com.
Already have an account?
Log in now
(your username is your email address)
Need to create a new account?
Register now
Log In:
Providers
I need to access...
Information about MA HMO and MA PPO members
Information about members in other plans
Log In:
Providers
Member information is available on provider.healthnetoregon.com.
Already have an account?
Log in now
(your username is your email address)
Need to create a new account?
Register now