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Commercial Rx PA Guidelines

Coverage of drugs is first determined by the member's pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage or Certificate of Insurance document for a list of exclusions and limitations.

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Legend:

natl = Applies to all lines of business in all Health Net regions (AZ, CA, OR)
hnca = Applies only to Commercial plans (HMO, POS, PPO, EPO, Healthy Families, AIM)
hnmc = Applies only to Health Net Medi-Cal

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A

Absorica Abstral - hnmc Abstral
Accretropin Aciphex Aciphex sprinkle
Actemra - hnmc Actemra Acticlate
Actimmune Actiq - hnmc Actiq
Actonel Adcirca Addyi
Adempas Adipex-p - hnca Adipex-p - hnmc
Afinitor Afinitor disperz Aldurazyme
Alecensa Allegra - hnmc Allegra-d 12 and 24 hour - hnmc
Alli - hnca Alli - hnmc Aloxi
Alsuma - hnmc Alsuma Altoprev - hnmc
Ambien cr - hnmc Amerge - hnca Amerge - hnmc
Amnesteem Ampyra - hnca Ampyra - hnmc
Amturnide - hnmc Amturnide Antara - hnmc
Antidepressant step therapy Anzemet Apidra
Aplenzin - hnmc Aplenzin Apokyn - hnca
Apokyn - hnmc Aptensio xr - hnmc Aptensio xr
Aralast np Aranesp - hnca Aranesp albumin free
Aranesp albumin free sure Aranesp - hnmc Arcalyst
Arixtra Astagraf xl Atelvia
Aubagio - hnca Aubagio - hnmc Auryxia
Avastin Avodart Avonex - hnca
Avonex - hnmc Axert - hnca Axert - hnmc
Axiron Azor - hnmc Azor

B

Belsomra - hnca Belsomra - hnmc Belviq - hnca
Belviq - hnmc Benicar - hnmc Benicar hct - hnmc
Benlysta Berinert - hnca Berinert - hnmc
Betaseron - hnca Betaseron - hnmc Binosto
Bivigam Boniva - hnmc Boniva
Bosulif Botox Bravelle
Breo ellipta Brisdelle Briviact
Bunavail Bydureon - hnca Bydureon - hnmc
Byetta - hnca Byetta - hnmc

C

Caduet Carimune nf Caverject
Celebrex Cerdelga - hnca Cerdelga - hnmc
Cerezyme Cesamet - hnca Cesamet - hnmc
Cetrotide Chantix - hnmc Chantix
Cholbam Cialis - hnca Cialis - hnmc
Cimzia - hnmc Cimzia Cinryze
Claravis Clarinex - hnmc Clarinex-d 12 and 24 hours - hnmc
Clarinex-d 12 and 24 hours Clarinex Commit - hnmc
Compounded medications Contrave - hnca Contrave - hnmc
Copaxone - hnca Copaxone - hnmc Copegus
Corlanor Cosentyx - hnmc Cosentyx
Cotellic Cresemba Crestor - hnmc
Crinone

D

Daklinza - hnmc Daklinza Daraprim
Ddavp - hnmc Desoxyn - hnca Desoxyn - hnmc
Desvenlafaxine fumarate etended-release tablets Desvenlafaxine fumarate extended-release tablets - hnmc Dexilant
Didrex - hnca Didrex - hnmc Diovan - hnmc
Diovan hct - hnmc Doryx Duexis
Duragesic - hnmc Dysport

E

Edarbi - hnmc Edarbyclor - hnmc Edex
Edluar - hnca Edluar - hnmc Egrifta
Elelyso Elidel Embeda
Enbrel - hnmc Enbrel Endometrin
Entresto Entyvio - hnmc Entyvio
Envarsus xr Epiduo forte Epogen - hnca
Epogen - hnmc Esbriet Esomeprazole strontium
Evista - hnmc Evzio Exforge - hnmc
Exforge hct - hnmc Extavia - hnca Extavia - hnmc
Eylea

F

Fabrazyme Falessa kit Fanapt
Farydak Fenoglide - hnmc Fentanyl citrate oral transmucosal - hnmc
Fentanyl citrate oral transmucosal Fentora - hnmc Fentora
Ferriprox - hnmc Fibricor - hnmc Firazyr - hnca
Firazyr - hnmc Flebogamma Flolan
Follistim-aq Forfivo xl - hnmc Forfivo xl
Forteo Fortesta Fosamax plus d
Fragmin Frova - hnca Frova - hnmc
Fulyzaq Fuzeon Fycompa

G

Gammagard Gammagard s d Gammaked
Gammaplex Gamunex Gamunex-c
Ganirelex Gattex Genotropin - hnca
Genotropin miniquick - hnca Genotropin miniquick - hnmc Genotropin - hnmc
Giazo Gilenya - hnca Gilenya - hnmc
Gilotrif - hnca Gilotrif - hnmc Glassia
Glatopa - hnca Glatopa - hnmc Glumetza
Gonal-f rff Gralise Granisol
Grastek - hnca Grastek - hnmc

H

Harvoni - hnmc Harvoni Hemangeol
Hetlioz Hizentra Hp acthar
Human growth hormone - hnca Human growth hormone - hnmc Humatrope - hnca
Humatrope combo pack - hnca Humatrope combo pack - hnmc Humatrope - hnmc
Humira - hnmc Humira Hyqvia
Hysingla er - hnmc Hysingla er

I

Iclusig Ilaris Imbruvica
Imitrex - hnca Imitrex injection - hnmc Imitrex injection
Imitrex - hnmc Immunoglobulin conditions not medically necessary Immunoglobulin for aneurysm in kawasaki syndrome
Immunoglobulin for b-cell cll Immunoglobulin for bacterial hiv in children Immunoglobulin for cidp
Immunoglobulin for dermatomyositis Immunoglobulin for guillain barre syndrome Immunoglobulin for itp
Immunoglobulin for kidney transplant Immunoglobulin for multifocal motor neuropathy Immunoglobulin for multiple myeloma
Immunoglobulin for multiple sclerosis Immunoglobulin for myasthenia gravis Immunoglobulin for neonatal alloimmune thrombocytopenia
Immunoglobulin for paraneoplastic disorders Immunoglobulin for parvovirus b19 infection Immunoglobulin for pemphigus vulgaris
Immunoglobulin for primary immunodeficiencies Immunoglobulin for stiff person syndrome Immunoglobulin hyperlinks
Incivek Increlex - hnca Increlex - hnmc
Infertility Inlyta Intermezzo - hnca
Intermezzo - hnmc Irenka Iressa
Itraconazole - hnca Itraconazole - hnmc

J

Jalyn Jublia Juxtapid

K

Kadcyla Kalbitor - hnca Kalbitor - hnmc
Kalydeco Kanuma Kerydin
Keveyis Khedezla - hnmc Khedezla
Kineret - hnmc Kineret Kitabis pak
Korlym Krystexxa Kuvan
Kynamro

L

Lamictal odt - hnca Lamictal odt - hnmc Lamictal xr - hnca
Lamictal xr - hnmc Lamisil granules - hnmc Latuda
Lazanda - hnmc Lazanda Lemtrada - hnca
Lemtrada - hnmc Lenvima Leukine
Levitra - hnca Lipofen - hnmc Livalo - hnmc
Livalo Locoid Lofibra - hnmc
Lonsurf Lotronex Lovenox
Lucentis Lumizyme Lunesta - hnmc
Luveris Lynparza - hnca Lynparza - hnmc
Lyrica - hnca Lyrica - hnmc

M

Macugen Makena Marinol - hnca
Marinol - hnmc Maxalt - hnca Maxalt mlt - hnca
Maxalt mlt - hnmc Maxalt - hnmc Mekinist - hnca
Mekinist - hnmc Menopur Minastrin 24 fe
Mircera - hnca Mircera - hnmc Mirvaso
Mitoxantrone - hnca Mitoxantrone - hnmc Morphabond er - hnmc
Morphabond er Morphine sulfate extended-release - hnca Mozobil
Muse - hnca Myalept Myobloc
Myorisan Myozyme

N

Naglazyme Namenda xr Namzaric
Narcan nasal spray Narcotic quantity limits - hnca Narcotic quantity limits - hnmc
Natesto Natpara Nesina
Neulasta Neumega Neupogen
Nexium Nicoderm cq Nicorette - hnmc
Nicorette Nicotrol inhaler - hnmc Nicotrol inhaler
Nicotrol ns - hnmc Nicotrol ns Ninlaro
Non formulary Norditropin - hnca Norditropin cartridge - hnca
Norditropin cartridge - hnmc Norditropin nordiflex pen - hnca Norditropin nordiflex pen - hnmc
Norditropin - hnmc Northera - hnca Northera - hnmc
Noxafil - hnmc Nplate - hnca Nplate - hnmc
Nucala Nucynta er - hnmc Nutropin - hnca
Nutropin aq - hnca Nutropin aq pen - hnca Nutropin aq pen - hnmc
Nutropin aq - hnmc Nutropin - hnmc Nuvessa
Nuvigil - hnca Nuvigil - hnmc

O

Octagam Ofev Olysio - hnmc
Olysio Omnitrope - hnca Omnitrope - hnmc
Onexton Onmel - hnca Onmel - hnmc
Opana er - hnca Opana er - hnmc Opsumit
Oracea Oralair - hnca Oralair - hnmc
Orencia - hnmc Orencia Orenitram
Orkambi Otezla Otrexup
Ovidrel Oxtellar xr Oxycontin - hnca
Oxycontin - hnmc

P

Panretin - hnca Panretin - hnmc Peg-intron
Pegasys Pennsaid - hnmc Pennsaid
Phentermine - hnca Phentermine Plegridy - hnca
Plegridy - hnmc Pomalyst Praluent
Prestalia Prevacid solutabs Prilosec powder
Pristiq - hnmc Pristiq Privigen
Procrit - hnca Procrit - hnmc Prolastin-c
Prolia Promacta - hnca Promacta - hnmc
Provenge Provigil - hnca Provigil - hnmc
Purixan

Q

Qsymia - hnca Qsymia - hnmc Qualaquin
Qudexy xr

R

Ragwitek - hnca Ragwitek - hnmc Ranexa
Rasuvo Ravicti Razadyne
Razadyne er Rebetol Rebif - hnca
Rebif - hnmc Reclast Regimex - hnca
Regimex - hnmc Regranex Relistor
Relpax - hnca Relpax - hnmc Remicade
Remodulin Repatha Repronex
Restasis Revatio Revlimid - hnca
Revlimid - hnmc Rexulti Risedronate
Rituxan Rozerem - hnca Rozerem - hnmc
Ruconest - hnca Ruconest - hnmc Rytary

S

Saizen - hnca Saizen click easy - hnca Saizen click easy - hnmc
Saizen - hnmc Sancuso Sandostatin - hnca
Sandostatin lar depot - hnca Sandostatin lar depot - hnmc Sandostatin - hnmc
Saphris Savella - hnca Savella - hnmc
Saxenda - hnca Saxenda - hnmc Seebri neohaler
Seroquel xr Serostim - hnca Serostim - hnmc
Signifor - hnca Signifor lar Signifor - hnmc
Silenor - hnca Silenor - hnmc Simponi - hnmc
Simponi aria - hnmc Simponi aria Simponi
Sitavig Soliris Solodyn
Somavert Sonata - hnmc Soolantra
Sotret Sovaldi - hnmc Sovaldi
Sporanox - hnca Sporanox - hnmc Spritam
Staxyn - hnca Stelara - hnmc Stelara
Stendra - hnca Stimate - hnmc Stivarga
Strensiq Suboxone Subsys - hnmc
Subsys Subutex Sumavel dosepro - hnmc
Sumavel dosepro Suprenza - hnca Suprenza - hnmc
Symlin - hnca Symlin pen - hnca Symlin pen - hnmc
Symlin - hnmc Synagis - hnmc Synagis

T

Taclonex Tafinlar - hnca Tafinlar - hnmc
Tagrisso Tanzeum - hnca Tanzeum - hnmc
Tarceva Tasigna - hnca Tasigna - hnmc
Tecfidera - hnca Tecfidera - hnmc Technivie - hnmc
Technivie Tekamlo - hnmc Tekamlo
Tekturna - hnmc Tekturna hct - hnmc Tekturna hct
Tekturna Tenuate - hnca Tenuate dospan - hnca
Tenuate dospan - hnmc Tenuate - hnmc Testim
Testosterone Tev-tropin - hnca Tev-tropin - hnmc
Teveten - hnmc Teveten hct - hnmc Teveten hct
Tier 3 drug exception Tivorbex Tobi
Tobi podhaler Tolak Treximet - hnca
Treximet - hnmc Tribenzor - hnmc Tribenzor
Tricor - hnmc Triglide - hnmc Trilipix - hnmc
Trokendi xr Trulicity - hnca Trulicity - hnmc
Tysabri Tyvaso Tyzeka

U

Uceris Uptravi

V

Valchlor Valcyte Vancocin
Veletri Veltassa Ventavis
Viagra - hnca Viberzi Victoza - hnca
Victoza - hnmc Vidaza Viekira pak - hnmc
Viekira pak Viibryd - hnmc Viibryd
Vimovo Vistogard Visudyne
Vivlodex Vogelxo Vpriv
Vraylar Vytorin - hnmc Vytorin 10 10 mg
Vytorin 10 80 mg

W

Wellbutrin xl

X

Xalkori - hnca Xalkori - hnmc Xartemis xr
Xeljanz - hnca Xeljanz - hnmc Xenical - hnca
Xenical - hnmc Xeomin Xerese
Xgeva Xiaflex Xifaxan - hnca
Xifaxan - hnmc Xolair Xtandi
Xtoro Xuriden Xyrem - hnca
Xyrem - hnmc Xyzal - hnmc Xyzal

Y

Z

Zarxio Zavesca - hnca Zavesca - hnmc
Zecuity - hnmc Zecuity Zegerid
Zelboraf Zemaira Zenatane
Zepatier - hnmc Zepatier Zipsor
Zofran Zohydro er - hnmc Zohydro er
Zolinza Zolpimist - hnca Zolpimist - hnmc
Zomacton - hnca Zomacton - hnmc Zomig - hnca
Zomig - hnmc Zorbtive - hnca Zorbtive - hnmc
Zorvolex Zovirax Zubsolv
Zuplenz Zurampic Zyban - hnmc
Zyban Zyclara Zydelig
Zyflo Zyflo cr Zykadia
Zytiga - hnca Zytiga - hnmc

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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