The subscriber number can be found on your Health Net Insurance card. Please enter the complete ID, including all letters and numbers. All letters must be typed as capital letters.
View our Frequently Asked Questions for answers to other common pharmacy-related questions.
1. How do I use my Health Net prescription benefit?
Once you obtain a prescription from your physician, you can receive up to a 30-day supply that can be filled at one of the Health Net participating pharmacies. Be sure to fill all non-emergency prescriptions at a participating pharmacy to ensure they will be covered under your pharmacy plan benefits.
2. How can I find a Health Net participating pharmacy?
You may access participating chain pharmacies anywhere in the United States, including Albertsons, Costco, CVS, Kmart, Longs, Rite Aid, Safeway, Sav-on, Shopko, Target, The Medicine Shoppe, Walgreen’s and Wal-Mart. You may also access the following pharmacies in the Northwest: Bi-Mart, Fred Meyer and Hi-School Pharmacy. Specialty Pharmacy medications must be obtained from one of Health Net’s designated Specialty Pharmacy providers.
To locate a participating pharmacy, search the Pharmacy Locator or call Customer Service at 1-888-802-7001.
3. How do I know what is included in my pharmacy benefit?
Consult your Prescription Benefits Supplemental Benefit Schedule for an accurate description of what is included in your Health Net pharmacy benefit. This includes copayments, coverage limits on quantity, dosage or strength, refills, and other related issues. Or, for more information, contact Health Net at 1-888-802-7001.
4. How do I know what my copayment will be?
There are several different copayment options available including three tiers and a Specialty Pharmacy provision. The tier (1, 2, 3 or SP) on the Preferred Drug List (PDL) corresponds to your applicable copayment. A lower tier generally indicates a lower copayment. To view your plan specific benefit, you may log in, and select "View Prescription Coverage" and then "copay amounts," or review your Prescription Benefits Supplemental Benefit Schedule, or contact Health Net at 1-888-802-7001.
Here are some tips:
6. What does Prior Authorization (PA) mean?
When a medication is noted on our preferred drug lists as "prior authorization required", your physician must contact us to provide the medical reasons for prescribing this medication. Upon receiving the necessary information, we will assess this information based on established clinical criteria for the particular medication.
7. What should I do if my medication requires Prior Authorization?
If your medication has a comment on the preferred drug list (PDL) that it requires prior authorization,or if your prescribed dose exceeds the quantity limit listed on the PDL, we recommend that you talk with your physician or medical provider as soon as possible about the prescribed medication and alternatives available. If your physician requests a prior authorization, we need to obtain information directly from your provider (this information cannot come from you, the patient). The provider may fax your prior authorization information using our Prior Authorization/Medication Exception Request Form to 1-800-255-9198. If urgent, your physician may call us at: 1-888-802-7001.
If your prior authorization criteria are met, then the drug is approved for coverage at the applicable copayment or coinsurance. If you decide to purchase without prior authorization, you will be responsible for the total cost of the medication or the Tier 3 copayment as applicable.
8. What does it mean if my drug has a quantity limit?
Some medications may be subject to a dosage – or quantity – limit. This means that you can get a pre-set amount of the medication within a specific time period. If your medication has a quantity limit, but you have been prescribed a dose that exceeds the limit, your physician must obtain prior authorization for the higher quantity.
The medication will not be prior authorized if: medical necessity criteria are not met; there is a less costly alternative; or the medication is not a covered benefit. If you decide to purchase the medication without prior authorization, you will be responsible for the total cost.
9. How often can I refill my prescriptions?
You may refill prescriptions for up to a 10-day supply after 50 percent of the medication from the previous fill has been used as directed. Prescriptions for more than a 10-day supply of medication are eligible for refill after 74 percent of the medication has been used as directed. If your physician has increased your dose, the physician needs to notify your pharmacy of the change in directions. Your pharmacy may contact Health Net for an override if this change will result in an early refill request.
10. Is there a mail order pharmacy program?
Yes. However, a mail order pharmacy program is generally used for maintenance medications, which are drugs that are taken for an extended period due to a chronic medical condition. Our Prescriptions by Mail program may allow you to receive up to a 90-day supply of maintenance medications each time you fill a prescription at mail order. Consult your Prescription Benefits Supplemental Benefit Schedule to determine if your plan has a mail order benefit.
11. What if a medication is not on a Health Net Drug List? Does that mean it's not covered?
Some generic and brand-name medications are secondary choices due to side effects, therapeutic performance, and/or high cost. If your medication is not on this list or there are comments that you do not understand, please call the Health Net Customer Contact Center at your earliest convenience at 1-888-802-7001 to help avoid interruption of a prescription.
The representatives will answer your questions, suggest alternative medications if your drug is not on this list, or explain the steps you need to take if your drug requires prior authorization. Generally, drugs not listed are subject to your tier 3 copayment, unless excluded by your pharmacy benefit.
12. How are injectable medications covered?
Injectable medications that appear on the Preferred Drug List are part of the pharmacy benefit. If you do not find your injectable medication listed on the Drug List, contact Health Net's Customer Contact Center for benefit information.
13. How are compounded prescriptions covered?
Compounded prescriptions may require Prior Authorization for coverage and are subject to your highest copayment if approved. Contact Health Net at 1-888-802-7001 and ask to speak with a Pharmacy representative of the Pharmacy Services department.
14. Who develops the list of medications included on the Health Net Drug List?
The preferred drug lists are developed and updated by the Health Net Pharmacy and Therapeutics (P&T) Committee, which consists of practicing physicians and pharmacists who are chosen based on their experience, knowledge and expertise in their specialties. Other external physician experts are consulted to provide input. The lists are updated regularly. The latest versions are available online. For more information, call Health Net at 1-888-802-7001.
15. How do I request reimbursement for prescriptions I purchased out-of-pocket?
We recommend that you fill prescriptions at participating pharmacies whenever possible. However, you may be eligible for reimbursement (minus the copayment) on prescriptions filled by an out-of-network pharmacy for emergency medical care rendered.
16. How do I submit a claim for reimbursement?
Mail a copy of your prescription receipts (not cash register receipts) together with the member's name, Health Net ID number and daytime phone number to:
Health Net of Oregon
Attn: Pharmacy Claims
P.O. Box 10350
Van Nuys, CA 91410-0350
Claims must be submitted within one year of the date of service. If a reimbursement is due to you, a check will be mailed within 30 days of our receipt of your claim.
17. Health Net is my secondary insurance. Am I eligible for reimbursement of my prescription copayments with my primary insurance?
If Health Net is not your primary plan, you may be eligible for secondary reimbursement from Health Net on prescription drugs. To determine eligibility, please send your detailed prescription receipts (not cash register receipts) together with the Explanation of Benefits statement (EOB) from your primary insurance to Health Net. If the primary EOB is not available, send a copy of your primary insurance plan card and include a daytime phone number where we can contact you if needed. Claims must be submitted within one year of the date of service. Please mail to:
Health Net of Oregon
Attn: Pharmacy Claims
P.O. Box 10350
Van Nuys, CA 91410-0350
18. What if I am on a medication that was covered by my previous health insurance?
Under the Continuity of Care Policy, within the first 90 days of Health Net coverage members may receive authorization for an existing medication requiring prior authorization that was covered under their previous health insurance company. This policy excludes the following:
The health plan will require verification that the medication was covered by the previous insurance company.
19. How are diabetic supplies covered?
The Health Net pharmacy benefit covers insulin, lancets, needles, syringes and blood glucose test strips. Although these items are available over-the-counter, you must have a prescription in order for the pharmacy to process the claim.
Health Net's preferred brands are Accu-Chek® Aviva, Accu-Chek® Compact Plus, Freestyle Flash® and Freestyle Freedom®, and Precision Xtra monitors.
20. Is Sudafed or any product containing pseudoephedrine covered under my pharmacy benefit?
Effective July 1, 2006, the state of Oregon requires a prescription for pseudoephedrine (Sudafed) and all over the counter products containing pseudoephedrine. Your pharmacy benefit does not cover any drug for which there is an over the counter therapeutic equivalent available. The over the counter therapeutic equivalent for Sudafed is Sudafed PE, and the over the counter therapeutic equivalent for Claritin-D is loratadine with Sudafed PE.
If you have any other questions, contact Health Net at 1-888-802-7001.