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Coverage Determinations and Redeterminations for Drugs

A coverage determination (exception) is a decision about whether a drug prescribed for you will be covered by us and the amount you'll need to pay, if any. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.

You can ask us to cover:

  • A drug that is not on our List of Drugs (Formulary)
  • A drug that requires prior approval.
  • A drug at a lower cost sharing tier, as long as the drug is not on the specialty tier (Tier 5).
  • A higher quantity or dose of a drug.

You, your representative, or your doctor may submit a coverage determination request by fax, mail, or phone. You must include your doctor's statement explaining why the drug is necessary for your condition. Within 72 hours after we receive your doctor's statement, we must make our decision and respond. If we deny your request, you can appeal our decision. Information on how to file an appeal will be included in the denial letter.

Generally, we will approve your request only if the alternative drug is on our list of drugs, or if a lower cost-sharing drug or added restrictions don't treat your condition as well. The contact information is listed below.

Drug Coverage Determination Forms

You can ask for a coverage determination (exception) one of the following ways:

Mail:
Health Net
Medicare Pharmacy Prior Authorization Department
P.O. Box 31397
Tampa, FL 33631-3397

FAX: 1-866-226-1093

Phone: Member Services or refer to the number on the back of your Member ID card

For Doctors and Other Prescribers ONLY

  • Electronic Prior Authorization (ePA): Cover My Meds prior authorization portal
  • Phone: 1-800-867-6564 (TTY: 711)

Standard and Fast Coverage Determination Decisions

If you or your doctor believe that waiting 72 hours for a standard decision could seriously harm your health, you can ask for a fast (expedited) decision. This is only for Part D drugs that you have not already received. We must make expedited decisions within 24 hours after we get your doctor’s supporting statement. If we do not receive your doctor's supporting statement for an expedited request, we will decide if your case requires a fast decision.

If we approve your drug's exception, the approval will be until the end of the plan year. To keep the exception in place, you must remain enrolled in our plan, your doctor must continue to prescribe your drug, and your drug must be safe for treating your condition.

After we make a coverage decision, we send you a letter explaining our decision. The letter includes information on how to appeal a denied request.

Prescription Reimbursement

If you need to ask for reimbursement for prescriptions paid out-of-pocket:

  1. Complete the Prescription Claim Form.
  2. Attach the original prescription receipt to the form. If you do not have the original receipt, you can ask your pharmacy for a printout. Do not use cash register receipts.
  3. Mail the completed form and receipt to the address on the form.

After we receive your request, we will mail our decision (determination) with a reimbursement check (if applicable) within 14 days. For specific information about drug coverage, refer to your Evidence of Coverage (EOC) or contact Member Services.

Redeterminations (Appeals)

If we deny your request for coverage of (or payment for) a drug, you, your doctor, or your representative may ask us for a redetermination (appeal). You have 60 days from the date of our coverage denial letter to request a redetermination. You can complete the Redetermination form, but you do not have to use it. You can send the form, or other written request, by mail or fax to:

Health Net
Attn: Medicare Pharmacy Appeals
P.O. Box 31383
Tampa, FL 33631-3383
Fax: 1-866-388-1766

An expedited redetermination (appeal) request can be made by phone at Member Services or refer to the number on the back of your Member ID card.

If you or your doctor states that waiting 7 days for a standard decision could seriously harm your health or ability to regain maximum function, you can ask for a fast (expedited) decision. If your doctor states this, we will automatically give you a decision within 72 hours. If we do not receive your doctor's supporting statement 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.

Drug Coverage Redetermination Forms

Other Forms

For more information about coverage determinations (exceptions) and redeterminations (appeals), please refer to your Evidence of Coverage (EOC).

Last Updated: 01/04/2023