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 may contact us and request a coverage determination.
Members can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested.
- Members can ask us to cover their 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.
- Members can ask us to waive coverage restrictions or limits on their drug. For example, for certain drugs, Health Net may limit the amount of the drug that will be covered. If a drug has a quantity limit, members can ask us to waive the limit and cover more.
- Members can ask us to make an exception and cover their drug at a lower tier. Drugs on the Preferred Brand tier and Specialty tier are not 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.
- COVERAGE DETERMINATION PROCESS
To request an exception or to obtain prior authorization, members or their 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 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 (this is sometimes called an adverse coverage determination), 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
Members: Contact Customer Service
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.
To protect personal health information and privacy, please do not send emails to Health Net using your 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.
Log in to the Secure Messaging Center. Select Compose. You will be prompted to enter an email address in the To: field. Paste firstname.lastname@example.org in the To: field. Please attach any supporting or relevant documents to your secure email message.
Health Net Pharmacy Department
PO Box 9103
Van Nuys, CA 91409-9103
- 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.
Information last updated 10-18-2013