Pharmacy Information for Providers

Overview

Need quick access to our drug lists and pharmacy forms? You're in the right place. Here, you can find the most current information on drug coverage for both Medicare and commercial plans. Download Prior Authorization and other related forms at your convenience. Check the Pharmacist Resource Center for regular updates on changes in coverage and other pharmacy-related news.

Pharmacist Resource Center

Our Pharmacist Resource Center links pharmacists to important information about our prescription drug plans and our latest pharmacy updates.

Prior authorization required

• Prior Authorization for Commercial Plans
• Prior Authorization for State Health Programs
• Prior Authorization Medicare Plans

Drug lists

Our formularies or drug lists include covered drugs that are selected by Health Net pharmacists, along with a team of health care providers. These drugs are chosen because they are believed to be a necessary part of a quality treatment program.

Use the Member Drug List Lookup Tool, view Member Pharmacy information or view Drug Lists by plan type:

• Drug Information for Commercial Plans
• Drug Information for Medicare Plans
• Drug Information for California State Health Programs

Important pharmacy information

• Pharmacy and Prior Authorization Forms

Member drug list lookup

Need to see a particular member's drug list?

• Use the Drug List Lookup Tool

Drug information for commercial plans

Individual, family and group drug lists

Our drug lists are selected by Health Net, along with a team of health care providers. These drugs are included because they are believed to be a key part of a quality treatment program. The drug lists are updated regularly and may change.

Please contact us if you need help finding the drug list that applies to your plan.

Affordable Care Act Exchange Drug List

(for On/Off Exchange, Individual and Small Group Plans)

• 2025 – CA Essential Drug List for Ambetter from Health Net (PDF)
• 2026 – CA Essential Drug List for Ambetter from Health Net (PDF)
• Alternative Drug List (PDF)

Commercial Drug Lists

• 2-Tier Recommended Commercial Drug List (PDF)
• 3-Tier Recommended Commercial Drug List (PDF)
• 4-Tier Recommended Commercial Drug List (PDF)
• Alternative Drug List (PDF)

Aon Benefit Experience Drug Lists

• 2025 Aon Benefit Experience Drug List (PDF)
• 2026 Aon Benefit Experience Drug List (PDF)

Searchable Drug List Tools (for the most up-to-date drug lists)

• CA Essential Drug List for Ambetter from Health Net
• 2-Tier Recommended Commercial Drug Tool
• 3-Tier Recommended Commercial Drug Tool
• 4-Tier Recommended Commercial Drug Tool

Drug information for California state health programs

Our drug lists or formularies include a comprehensive list of covered drugs selected by Health Net, along with a team of health care providers. These drugs are selected because they are believed to be a necessary part of a quality treatment program. Our drug lists are updated regularly and are subject to change.

Printable drug lists

• Medi-Cal Rx Contract Drug List

Educational articles

Published as a component of California's Medi-Cal Drug Use Review (DUR) Program by the Department of Health Care Services (DHCS), the purpose of the DUR educational articles is to alert and educate pharmacists and prescribers on clinically important drug therapy issues and potentially unsafe practices identified during a review of outpatient drug prescribing patterns.

• Medi-Cal DUR Educational Articles

Drug information for Medicare plans

• Drug and Pharmacy Information
• Drug Transition Policy
• Prior Authorization, Step Therapy and Quantity Limits
• Medicare Part B Step Therapy (PDF)
• 2026 Covered Drug Alternatives – Wellcare By Health Net (PDF)

Prior authorization for Commercial plans

For some drugs, your doctor must get approval from us before you fill your prescription. This is called prior authorization. We may not cover the drug if you don't get approval.

To request prior authorization, your prescriber must complete a Prescription Drug Prior Authorization or Step Therapy Exception Form – Commercial and Medi-Cal (PDF) and fax it to 866-399-0929.

• View Our Prior Authorization Guidelines

Once we receive the request, we will review it to see if it can be approved. If we deny the request, we will tell you why it was denied. We will also tell you how to appeal the decision.

Prior authorization for State Health programs

Your pharmacy benefit is administered by Medi-Cal Rx, and they are responsible for your authorizations.

To request prior authorization, your prescriber must complete a Prior Authorization Form and fax it to 800-869-4325.

• Web: Medi-Cal Rx
• Fax: 800-869-4325

Coverage determinations for drugs – exceptions and prior authorization

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.

Exceptions

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:

• Cover a drug even if it is not on our formulary. Please note that if we grant a request to cover a drug that is not on our formulary, the drug will be available for the non-preferred brand tier copayment. The drug is not eligible for an exception for payment at a lower tier.
• Waive coverage restrictions or limits on a drug. For example, Health Net may limit the amount of a drug that will be covered. If a drug has a quantity limit, members can ask us to waive the limit and cover more.
• Cover a drug at a lower tier. Drugs on the preferred brand tier and Specialty tier may not be eligible for an exception for payment at a lower tier.

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.

Prior authorization - Pharmacy

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.

• View A List Of Drugs Subject To Prior Authorization

Coverage determination process

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.

Standard & fast decisions

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.

Contact information

Phone

Prescribers: 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.

Email

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.

1. Log in to the Secure Messaging Center.
2. Select Compose.
3. You will be prompted to enter an email address in the To: field.
   Paste medicaredeterminations@healthnet.com in the To: field.
4. Please attach any supporting or relevant documents to your secure email message.

Mail

Health Net Prior Authorization Department
PO Box 419069
Rancho Cordova, CA 95741-9069

Fax

• Commercial members: 866-399-0929
• Medi-Cal members Pharmacy PA: 800-869-4325

More information

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.

Site of Care Optimization for Therapeutic Infusions (SCOTI) – 1^st Quarter 2026

Changes that improve patient experience, enhance patient safety and encourage medication adherence

Effective January 1, 2026, Health Net* is enhancing infusion care access by partnering with Coram^® CVS Specialty™ Infusion Services, offering eligible Commercial (HMO, POS, PPO) and Exchange members more flexibility in where they receive therapeutic infusions. Members can now choose from:

Alternative sites of therapeutic infusion care

• Home
• Medical office settings
• Ambulatory Infusion Suites (AIS) in Ontario and San Diego

These options are part of standard member benefits and designed to improve convenience, safety and affordability.

Coram provides:

• Trusted expertise − Coram brings over 40 years of specialized infusion care and is the only national home infusion provider accredited by the Joint Commission.
• Safe, high-quality care − Certified clinicians and nurses deliver and monitor complex therapies with clinical support, available 24 hours a day, 7 days a week.
• Convenience and flexibility − Infusions can be scheduled around your life, empowering independence and improving quality of life.
• Cost savings and better outcomes – Injections (including infusions) outside the hospital may reduce costs, promote therapy adherence and improve outcomes.

Eligible infusion therapies

A wide range of conditions and medications are eligible for home or alternative site infusion.

_{¹ Health Net prefers these biosimilar products over Remicade: Inflectra (infliximab-dyyb), Renflexis (infliximab-abda).}

_{² First two doses of Xgeva are given in the Ontario and San Diego locations.}

_{³ Coram can coordinate with CVS Specialty, Inc to have this injection delivered to the doctor’s office for administration.}

_{⁴ First dose of Ocrevus is infused in the Ontario and San Diego locations. Other multiple sclerosis agents, such as Lemtrada and Tysabri, are also eligible for alternative site of infusion care in the Ontario and San Diego locations.}

Coverage and coordination details

Eligibility for the SCOTI program depends on financial responsibility between Health Net and the member's participating physician group (PPG).

If Health Net is financially responsible:

• Use Coram CVS Specialty Infusion Services.
• Coram will coordinate directly with physicians and other providers, including prior authorization and scheduling.

If the PPG is financially responsible:

• PPGs are not required to use Coram.
• Physicians and other providers should arrange home infusion through the PPG's contracted home health vendor.

PPGs should refer to the Health Net Injectable Medication HCPCS/DOFR Crosswalk to confirm DOFR categorization of medications and financial responsibility.

Referrals and Contact Information

To refer patients to alternative sites of care (including home infusion), contact Coram:

• Phone: 866-899-1661
• Fax: 866-843-3221

Be sure to reference the SCOTI program if contacting Coram for referrals.

For additional information, contact the Health Net Pharmacy Team Mailbox at pharmsvs@centene.com and reference the SCOTI Program.

Need help? Contact us

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center:

• Email: provider_services@healthnet.com
• Phone:
  • Ambetter from Health Net IFP Ambetter HMO – 888-926-2164
  • Ambetter from Health Net IFP Ambetter PPO − 844-463-8188
  • Health Net Employer Group HMO, POS & PPO − 800-641-7761
• Online: Health Net Provider portal

Behavioral health providers call 844-966-0298.

_{* Health Net of California, Inc. and Health Net Community Solutions, Inc. are subsidiaries of Health Net, LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC. All other identified trademarks/service marks remain the property of their respective companies. All rights reserved.}

Forms

• Prescription Drug Prior Authorization or Step Therapy Exception Form – Commercial and Medi-Cal (PDF)
• Prescription Drug Prior Authorization or Step Therapy Exception Form – CalViva Health (PDF)
• Prescription Drug Prior Authorization or Step Therapy Exception Form – Community Health Plan of Imperial Valley (PDF)
• Medicare Part D Coverage Determination Request Form (PDF)

Pharmacist Resource Center

View our latest pharmacy updates in the table below.