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)

• Health Net Essential Drug List for Small Groups (PDF)
• 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)
• 3-Tier with Specialty Commercial Drug List (PDF)
• Alternative Drug List (PDF)

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

• Health Net Essential Drug list for Small Groups
• CA Essential Drug List for Ambetter from Health Net
• 2-Tier Recommended Commercial Drug Tool
• 3-Tier Recommended Commercial Drug Tool
• 3-Tier with Specialty 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

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 Prior Authorization Form (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: 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.

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)

Line of business: Commercial and Exchange

Health Net* has partnered with Coram^® CVS Specialty™ Infusion Services as the designated preferred provider for site of care optimization for therapeutic infusions (SCOTI). Members have the option to transition infusions from the hospital to the home and an ambulatory infusion suite (AIS) located in the Ontario and San Diego facilities. Alternate site of infusion care is part of a member's standard benefit. The Plan has options available for members who are being treated with any of the infusion products listed in the table below.

Coram provides:

• Experience. More than 35 years of expertise in specialized infusion care. The only national home infusion provider accredited by The Joint Commission.
• Safety. Certified clinicians and nurses deliver and track complex drug therapy to ensure patients receive high-level care.
• Convenience. Scheduling is easy with in-home and AIS-based infusions located in Ontario and San Diego. Patients can enjoy flexibility, independence and enhanced quality of life. Clinical support is available to patients 24 hours a day, seven days a week.
• Lower costs. Infusions may be provided at a lower cost to promote compliance to therapy, improve outcomes and reduce health costs.

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

_{² 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.}

Home infusion coverage

Home infusion services are a covered benefit for Commercial and Exchange members. Use of the SCOTI program depends on whether Health Net or the member's assigned participating physician group (PPG) is financially responsible for the service.

PPGs should consult the Health Net Injectable Medication HCPCS/DOFR Crosswalk to determine the DOFR categorization of medications to determine the financial responsibility. The intent of the DOFR category of Home Health is to include only those medications in the crosswalk with the Home Health Infusion category.

• Health Net has financial responsibility: Use Coram CVS Specialty Infusion Services for the home infusion medications included in this communication. Coram will work directly with the provider to arrange home infusion. This includes obtaining required documents for prior authorization and scheduling the member for services.
• PPG has financial responsibility: PPGs that have financial responsibility for home infusion are not required to use Coram CVS Specialty Infusion Services or any of the home infusion medications included in this communication. Providers should work directly with the member's assigned PPG to arrange home infusion using the PPG's contracted home health vendor.

Additional information

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

Last revised: March 2023

Forms

• Health Net Prior Authorization Form (for prescribers) (PDF)
• Medicare Part D Coverage Determination Request Form (PDF)

Pharmacist Resource Center

View our latest pharmacy updates in the table below.