Our formulary or drug list is a list of covered drugs selected by our team of health care providers. We include these drugs because we believe they are an important part of a quality treatment program. Formularies are updated regularly and may change at any time. You will receive notice when necessary.
Plan | Printable PDF |
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Health Net Seniority Plus (Employer HMO) |
We may add or remove drugs from our formulary during the year. If we remove or change Part D drugs from our formulary, add prior authorization or quantity limits on a drug and/or move a drug to a higher cost-sharing tier, we will notify members and providers of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. You can view any changes that have been made to the formulary by clicking on the link below.
You can look for network pharmacies with our Find a Pharmacy tool.
Our Medication Therapy Management (MTM) program is offered at no cost to eligible members. The MTM program helps members learn how to get the most from their medication.
To be eligible for the MTM program, members must:
All eligible members are automatically enrolled in the program. Though this program is not called a benefit, it's offered at no charge to our members.
Once members are enrolled in the program, a pharmacist reviews each member's pharmacy records. Members get a Welcome letter about any issues found by the pharmacist. The Welcome letter invites members to call a pharmacist to ask questions about their drugs. The Welcome letter also tells members how to call and ask for a comprehensive medication review (CMR).
A CMR is a complete review of all of the drugs each member takes. This includes prescription and over-the-counter drugs, vitamins and herbal supplements. A CMR takes about 30 - 60 minutes. Pharmacists work with members to create a plan for any problems found in the review. Pharmacists may discuss any problems found during the CMR with doctors or other prescribers when needed. A member can call us and ask for a CMR or a pharmacist may call a member to offer a CMR.
As part of a CMR, pharmacists create a personal list of medications for members. Members can also print and fill out a blank personal medication list (pdf) at any time.
Every three months or so, our pharmacists review every MTM members’ pharmacy records for any new problems. After each review, we send a letter to the member that lists any issues. The letter also suggests ways to help improve medication use.
To find out more about our MTM program or to get copies of MTM documents, you may contact us .
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
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.
You will be sent a transition letter when we cover a transition supply of your drug. The transition letter is member-specific and is available for free in another format or language upon request. 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 to help you understand and keep track of payments for your Part D prescription drugs. The Explanation of Benefits is member specific and is available for free in another format or language upon request.
With our nationwide network of pharmacies, it's easy to get your prescriptions filled using your pharmacy benefits. However, we understand you may not always be able to use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:
Before you have your prescription filled in these situations, contact us to check if there is a network pharmacy in your area that can fill your prescription.
In most cases, your claim will be automatically submitted when you have your prescription filled at a network pharmacy. However, if you go to an out-of-network pharmacy, they may not submit the claim directly to us. In these cases, you must pay the full cost of your prescription upon receipt. You may then submit a Medicare Prescription Claim Form (pdf) to request a reimbursement of our share of the cost.
Mail the completed form and receipts to the address listed on the form. Once we receive your claim, we will mail our determination with a check, if applicable, to you within 14 days.
Refer to your Evidence of Coverage for specific information about drug coverage and limitations. If you have questions about this process, please contact us .
Information last updated 09-01-2015
Health Net has a contract with Medicare to offer HMO, PPO and HMO SNP plans. Health Net has a contract with Medicare and Medicaid to offer HMO SNP plans. Enrollment in a Health Net Medicare Advantage plan depends on contract renewal.
Y0020_2017_0035_A CMS Approved 12022016
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