Our Drug List shows the drugs we cover. Look below to find the drug list in your language. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

• English (pdf)
• Español (pdf)
• Arabic (pdf)
• Armenian (pdf)
• Chinese (pdf)
• Cambodian (pdf)
• Farsi (pdf)
• Korean (pdf)
• Russian (pdf)
• Tagalog (pdf)
• Vietnamese (pdf)

You can look for network pharmacies with our Pharmacy Search tool.

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. We also list pharmacies that are in our network but are outside your plan's service area. Generally, you must use network pharmacies except in emergency or urgent care situations. If you want a Provider and Pharmacy Directory mailed to you, or if you need help finding a network pharmacy, please contact us .

The transition program is for new and renewing members who are taking drugs that are not on the Drug List or are on the Drug List with a restriction (not based on safety). This includes both Part D and Medi-Cal drugs.

We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of our plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We may cover a 30-day supply of your drug if:

• you are taking a drug that is not on our Drug List, or
• health plan rules do not let you get the amount ordered by your prescriber, or
• the drug requires prior approval by Health Net Cal MediConnect, or
• you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the first 90 days. This gives your prescriber time to change your drugs to those on the Drug List or ask for an exception.

Emergency Supply

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

Level of Care Changes

If your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.

• If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply.
• If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply.

Transition Letter

You will be sent a transition letter when we cover a transition supply of your drug. You can ask for the transition letter in another format or language. To ask for the letter in another format or language, please contact us .

When you use your Part D prescription drug benefits, we will send you an Explanation of Benefits (EOB). The EOB helps you keep track of drug costs. You can get the EOB in another format or language. To get the EOB in another format or language, please contact us.

We have thousands of pharmacies in our network to make it easy to get your drugs at a network pharmacy. But we know there may be times when you can't use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:

• There is no network pharmacy that is close to you and open.
• You need a drug that you can't get at a network pharmacy close to you.
• You need a drug for emergency or urgent medical care.
• You must leave your home due to a federal disaster or other public health emergency.

Always contact us first to try finding a network pharmacy close to you.

In most cases, network pharmacies send your claim to us when you pick up your drugs. Out-of-network pharmacies may not send the claim to us. In these cases, you must pay the full cost of your drugs up front. You can ask us to pay you back for our share of the cost.

Submitting a claim

• Complete the Prescription Claim Form (pdf).
• Attach your original prescription receipt(s) to the form. Cash register receipts may not be used.

Mail the form and receipt to:

Health Net Community Solutions, Inc.
Attn: Pharmacy Claims
PO Box 419069
Rancho Cordova,
California 95741-9069

Once we receive your claim form, we'll respond within 14 days.

For questions about your benefits, check your Member Handbook or contact us.

An "appeal" is a request that you make when you want us to change a decision we have made about what is covered or what we will pay for. You need to send an appeal request regarding medical care by 60 calendar days from the date on the denial letter that you get from us. After 60 days, Health Net can take an appeal request if you give us a good reason. This also applies for Part D; you need to send an appeal request regarding Part D prescription drugs by 60 calendar days from the date on the denial letter that you get from us. After 60 days, Health Net can take an appeal request if you give us a good reason.

To ask for an appeal, you can call, mail, fax, or submit a request online as outlined in the "How to File an Appeal or Grievance" section below. If you submit via Mail or Fax, please put dates, times, names of people and places in your letter. Or you can fill out the Medical Services – Reconsideration Form (below). You do not need to use the form if you do not want to. Please include copies of any information about your appeal in the letter and mail to:

Medical Services:

Health Net
Attn: Appeals & Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422

Prescription Services:

Health Net
Attn: Appeals & Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422

You may also call us at 1-855-464-3571 (Los Angeles); 1-855-464-3572 (San Diego County). Send your letter by mail, e-mail or fax to the address(s) and/or fax number listed below in the How to File section.

How soon we decide on your appeal depends on the type of appeal:

For a decision to authorize medical care and payment (including Tier 3 drugs) of services: For Medicare and Medi-Cal covered services, we will give you a written decision within 30 calendar days after we get your appeal. For Medicare covered services, a decision about payment for services and claim payment will be provided within 60 calendar days after we get your appeal. For Medi-Cal covered services, a decision about your payment for services and claim payment will be provided within 30 calendar days after we receive your appeal. We will make it sooner if your health requires. If we need more information to review your appeal for services you have not received, we may ask you for more time. You may ask us for more time for services you have not received (an extension) if you need to get more information to send to us. We will tell you if we are taking extra time and we will explain why we need more time.

For a decision about payment for Part D prescription drugs you already received: After we get your appeal request, we have 7 calendar days to make a decision. If we decide in your favor, we have 30 days from the date of your appeal to send payment.

For a standard decision about Part D prescription drugs: After we get your appeal, we have up to 7 calendar days to decide. We will make it sooner if your health requires.

You, any doctor, or your representative can ask us to give you an expedited ("fast") appeal. We can give you a fast appeal only for drugs or services that you have not received yet. You can ask for a fast appeal if you or your doctor think that waiting could seriously harm your health. If we give you a fast decision, we will decide no later than 72 hours of getting your request. For a fast appeal, contact us by telephone or fax at the number listed below in the How to File section.

For denials of medical appeals for Medicare covered services (including services that are covered by both Medicare and Medi-Cal): If we deny any part of your medical appeal, your case will be sent to an independent review organization. This independent review organization contracts with the Federal government and is not part of our Plan.

For denials of medical appeals for Medi-Cal covered services: You may request a State Fair Hearing at anytime without asking us (health plan) to review our decision first. Your request must be submitted in writing. The request must include:

• Your name
• Address
• Member number
• Reasons for appealing
• Any evidence you want us to review, such as medical records, doctor's letters, or other information that explains why you need the item or service. Call your doctor if you need this information.

Send your request to:

State Hearings Division
Department of Social Services
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

You may be able to get an IMR right away without filing an appeal first. This is in cases where your health is in immediate danger or the request was denied because treatment was considered experimental or investigational. If you disagree with our decision, you can request an IMR. You cannot ask for an IMR if you already asked for a State Fair Hearing on the same issue. The paragraph below will provide you with information on how to request an IMR. Note that the term “grievance” is talking about both "complaints" and "appeals." To request an IMR:

• Fill out the Complaint/Independent Medical Review (IMR) Application Form available at dmhc.ca.gov - Independent Medical Review Application Form or call the DMHC Help Center at 1‑888‑466‑2219. TDD users should call 1‑877‑688‑9891.
• Attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents.
• Mail or fax your form and any attachments to:
  

  Help Center
  Department of Managed Health Care
  980 Ninth Street, Suite 500
  Sacramento, CA 95814-2725
  FAX: 916-255-5241

For denials of Part D appeals: If we deny any part of your Part D appeal, you or your representative can mail or fax your written appeal request to the independent review organization. Send a written appeal request to:

MAXIMUS Federal Services
3750 Monroe Ave., Suite #703
Pittsford, NY 14534-1302

Fax number for enrollees: 1-585-425-5390

The independent reviewer will look at our decision. If any of the medical care or service you asked for is still denied, you can appeal to an Administrative Law Judge (ALJ). You will be notified of your appeal rights if this happens.

There is another special type of appeal that is only for when coverage will end for SNF (Skilled Nursing Facility), HHA (Home Health Agency) or CORF (Comprehensive Outpatient Rehabilitation Facilities) services. If you think your coverage is ending too soon, you can appeal at once to Livanta. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. Livanta is an independent organization. It is not connected with our plan. See "How to File" section below to contact Livanta.

• If you get the notice 2 days before your coverage ends, you must appeal no later than noon of the day after you get the notice.
• If you get the notice and you have more than 2 days before your coverage ends, then you must appeal no later than noon of the day before the date that your Medicare coverage ends.

Important Appeals Information

If you have questions about these appeal procedures, you may refer to the sections of the Member Handbook for your plan as outlined below. You can also call Health Net Customer Service at the phone number listed below in the How to File section.

As a Health Net member, you have the right to:

• Tell Medicare about your complaint by calling 1‑800‑MEDICARE (1‑800‑633‑4227; TTY/TDD Hearing Impaired 1‑877‑486‑2048), which is the national Medicare help line, 24 hours a day, 7 days a week. Or you may fill out the Complaint Form available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx
• Tell Medi-Cal about your complaint by calling the Cal MediConnect Ombuds Program at 1‑855‑501‑3077. The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program
• Obtain a total number of Health Net's complaints, appeals and exceptions, please call Health Net Customer Service at the phone number listed below in the How to File section.

If you want to ask about the status of an appeal, please call Health Net Customer Service at the phone number listed below in the How to File section.

A grievance is a complaint that you give to your health plan. You can file a complaint when you are unhappy with any service or benefit that you get from Health Net's Cal MediConnect Program. For example, you would file a complaint if you had a problem with:

• waiting times for appointments
• wait time in the waiting room
• the way your doctors or staff behave
• being able to reach someone by phone
• getting information you need from the doctor's office
• the cleanliness of the doctor's office

You can file your complaint with us or the provider at any time.

The Appeals and Grievances Department can only work on complaints filed against Health Net and our contracted providers.

You can send us a complaint using one of the ways below:

• Call Health Net's Customer Service Department
  Los Angeles: 1-855-464-3571    TTY 711
  San Diego: 1-855-464-3572       TTY 711
• Send a letter, fax (facsimile) or e-mail to Health Net at address listed below in the How to File section
• You may file a complaint through Cal MediConnect Ombuds Program
• For Medicare services, you may also file a complaint through 1-800-Medicare

The Customer Service Center will try to find an answer for your complaint right away. You can ask them to send you a letter that tells you what the answer was for your complaint. If the Customer Service Center can't help you right away, they will send the complaint to be researched.

We must get back to you with what we found out about your complaint as quickly as possible. We will send you a letter no later than 30 calendar days after we get your complaint.

If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," or we decided we need more time to review your request for a medical care or appeal of denied medical care we will automatically give you a "fast complaint" and respond to your complaint within 24 hours. If you have an urgent problem that involves an immediate and serious risk to your health, you can request a "fast complaint" and we will respond within 72 hours. We may take up to 14 more calendar days if we need more information from you or your doctor for medical appeals on services you have not received. You can ask us for more time to send in information also.

If you have questions about these complaint procedures you may refer to the applicable sections of the member handbook. You can call Health Net Customer Service at the phone number listed below in the How to File section.

If you want to inquire about the status of a complaint, please call Health Net Customer Service at the phone number listed below in the How to File section.

As a Health Net member, you have the right to:

• Tell Medicare about your complaint by calling 1‑800‑MEDICARE (1‑800‑633‑4227; TTY/TDD Hearing Impaired 1‑877‑486‑2048), which is the national Medicare help line, 24 hours a day, 7 days a week. Or you may fill out the Complaint Form available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx
• Tell Medi-Cal about your complaint by calling the Cal MediConnect Ombuds Program at 1‑855‑501‑3077. The services are free. Or you may visit their website at: http://www.calduals.org/beneficiaries/ombudsman-program
• Obtain a total number of Health Net's complaints, appeals and exceptions, please call Health Net Customer Service at the phone number listed below in the How to File section.

For quality of care complaints, you may also complain to the Quality Improvement Organization (QIO)

Complaints about the quality of care received under Cal MediConnect can be reviewed by Health Net under the complaint process, by an independent organization called the QIO, or by both. For example, if a member believes he/she is being discharged from the hospital too soon, the member may file a complaint with the QIO in addition to a complaint filed under Health Net's grievance process. For any complaint filed with the QIO, Health Net will work with the QIO in resolving the complaint.

How to file a quality of care complaint with the QIO

Quality of care complaints filed with the QIO must be made in writing. A member who files a quality of care complaint with a QIO does not need to file the complaint within a specific time period. Please see below in the 'How to File an Appeal or Grievance' section for specific contact information.

You may file an appeal or grievance using the following methods:

• Call our Customer Service Department
  Monday through Friday, 8:00 a.m. to 8:00 p.m.
  At other times, including Saturday, Sunday and Federal Holidays, you can leave a voicemail.

  Health Net Cal MediConnect (MMP)- Los Angeles:	1-855-464-3571 TTY 711
  Health Net Cal MediConnect (MMP)- San Diego:	1-855-464-3572 TTY 711

  For Quality Improvement Organization (QIO) Complaints, please contact:

  Livanta
  BFCC-QIO Program
  9090 Junction Drive, Suite 10
  Annapolis Junction, MD 20701

  Toll-free Number:	1-877-588-1123
  TTY:	1-855-887-6668
  Appeals (Fax):	1-855-694-2929
  All other reviews (Fax):	1-844-420-6672

• By Submitting an Online Form (Use of Online Form is optional)

  Medical Appeal Form
  
  REQUEST FOR RECONSIDERATION (APPEAL) Part C
  Your request for reconsideration (appeal) must be made within 60 calendar days from the date of the initial denial decision. If your request for reconsideration (appeal) is submitted beyond 60 calendar days, please submit an explanation why you were unable to make your request within this timeframe.

  Health Net will make its reconsidered determination as expeditiously as your health requires, for Medicare and Medi-Cal covered services, we will give you a written decision within 30 calendar days after we get your appeal. For Medicare covered services (including services that are covered by both Medicare and Medi-Cal), a decision about payment for services and claim payment will be provided within 60 calendar days after we get your appeal. For Medi-Cal covered services, a decision about your payment for services and claim payment will be provided within 30 calendar days after we receive your appeal. We will make it sooner if your health requires. If we need more information to review your appeal for services you have not received, we may ask you for more time. You may ask us for more time for services you have not received (an extension) if you need to get more information to send to us. We will tell you if we are taking extra time and we will explain why we need more time.

  Prescription Drug Appeal Form
  
  Important Note: Expedited Decisions
  If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. We will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

  Grievance Form
  
  Use this form to formally express your dissatisfaction with the care or service(s) you have received. It will be submitted to the Appeals and Grievances Department for review and response back to you.

• By Mail or Fax

  You may mail your appeal or grievance via a written letter or by using one of our forms found below. Please mail or fax to:

  Prescription Drug Services and Medical Services:

  Health Net Community Solutions, Inc.
  Attn: Appeals & Grievances Dept.
  P.O. Box 10422
  Van Nuys, CA 91410-0422

  Fax: 1-877-713-6189

Forms
Medical Services – Reconsideration Form (pdf)
Prescription Drugs – Redetermination Form (pdf)

An appointed representative is a person who can act on your behalf to request an exception appeal or complaint. This person can be a relative, friend, advocate, doctor, or anyone else whom you trust to act on your behalf. If you want to appoint someone to act for you, then both you and that person must sign and date a statement that gives the person legal permission to act as your appointed representative. Please note that your physician or other prescriber is not required to submit a signed Appointment of Representative (AOR) form CMS-1696 or other equivalent notice. Physicians and other prescribers may request a redetermination on your behalf at any time without completing an AOR form.

You can use the AOR form or you can make your own statement.

The signed AOR form or other equivalent notice must be included with each oral or written request for an appeal or grievance. Unless revoked, an appointment is considered valid for one year from the date that the representative form is signed by both the member and representative. Also the representation is valid for the duration of the appeal or grievance. A photocopy of the signed representative form must be submitted with future appeals or grievances on behalf of the Member in order to continue representation. However the original or photocopied form is only valid for one year after the date of the member's signature.

• Appointment of Representative (AOR) form CMS-1696

You can use the form or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, Cal MediConnect may also accept other forms of legal documentation.

The required information of an 'equivalent written notice' is one that:

• Includes the name, address, and telephone number of enrollee;
• Includes the enrollee's HICN [or Medicare Identifier (ID) Number];
• Includes the name, address, and telephone number of the individual being appointed;
• Contains a statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement authorizing disclosure of individually identifying information to the representative;
• Is signed and dated by the enrollee making the appointment; and
• Is signed and dated by the individual being appointed as representative, and is accompanied by a statement that the individual accepts the appointment

Send your AOR form or equivalent written notice to:

Appeals and Grievances Dept.
P.O. Box 10422
Van Nuys, CA 91410-0422