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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.

View Medicare Prior Authorization Criteria

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

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

A

ABSORICA ABSTRAL ACANYA
ACIPHEX ACIPHEX SPRINKLE ACTEMRA - HNMC
ACTEMRA (pending P&T approval) ACTEMRA ACTICLATE
ACTIMMUNE ACTIQ ACTONEL
ACZONE ADAGEN ADCETRIS - HNMC
ADCIRCA ADDYI ADEMPAS
ADIPEX-P - HNCA ADIPEX-P - HNMC ADLYXIN - HNCA
ADLYXIN - HNMC ADZENYS ER ADZENYS XR-ODT
AFINITOR AFINITOR DISPERZ AIMOVIG
AJOVY (pending P&T approval) AKYNZEO - HNMC ALDURAZYME
ALECENSA ALIQOPA - HNMC ALLI - HNCA
ALLI - HNMC ALOCRIL - HNMC ALOMIDE - HNMC
ALOXI ALUNBRIG AMERGE
AMITIZA - HNMC AMPYRA ANNOVERA (pending P&T approval)
ANORO ELLIPTA - HNMC ANZEMET APIDRA
APLENZIN APOKYN APTENSIO XR
ARAKODA (pending P&T approval) ARALAST NP ARANESP ALBUMIN FREE - HNMC
ARANESP ALBUMIN FREE ARCALYST ARESTIN
ARIKAYCE (pending P&T approval) ARIXTRA AROMASIN - HNMC
ARYMO ER - HNMC ARYMO ER ARZERRA - HNMC
ASTAGRAF XL ATELVIA ATRIPLA - HNMC
ATRIPLA AUBAGIO - HNMC AUBAGIO
AURYXIA AUSTEDO AVASTIN
AVODART AVONEX - HNMC AVONEX
AXERT AZOR - HNMC AZOR

B

BANZEL - HNMC BASAGLAR KWIKPEN BAXDELA - HNMC
BAXDELA BELEODAQ - HNMC BELSOMRA - HNMC
BELSOMRA BELVIQ - HNCA BELVIQ XR - HNCA
BELVIQ XR - HNMC BELVIQ - HNMC BENDEKA - HNMC
BENICAR - HNMC BENICAR HCT - HNMC BENLYSTA
BENZNIDAZOLE BEPREVE BERINERT
BESPONSA - HNMC BETASERON - HNMC BETASERON
BETHKIS BEVYXXA - HNMC BINOSTO
BIVIGAM BLINCYTO BONIVA INJ
BONJESTA BOSULIF BOTOX
BRAFTOVI Brand Name Override Policy - HNCA BRAVELLE
BRINEURA BUNAVAIL - HNCA BUNAVAIL
BUPRENORPHINE HCL BYDUREON - HNCA BYDUREON - HNMC
BYETTA - HNCA BYETTA - HNMC

C

CABOMETYX CADUET CALQUENCE
CAMBIA CARIMUNE NANOFILTERED CAVERJECT
CELEBREX CERDELGA CEREZYME
CESAMET CETROTIDE CHENODAL
CHLORAMPHENICOL SODIUM SUCCINATE CHOLBAM CIALIS - HNCA
CIALIS CIMZIA - HNMC CIMZIA (pending P&T approval)
CIMZIA CINQAIR CINRYZE
CLARAVIS CLARINEX CLARINEX-D 12 HOUR
CLENPIQ COLYTE-FLAVOR PACKS COMETRIQ
COMPLERA - HNMC COMPLERA Compounded Medications
CONTRAVE - HNCA CONTRAVE - HNMC COPAXONE - HNMC
COPAXONE COPEGUS - HNMC COPEGUS
COPIKTRA CORLANOR COSENTYX - HNMC
COSENTYX (pending P&T approval) COSENTYX COTELLIC
COTEMPLA XR-ODT CRESEMBA CRESTOR - HNMC
CRINONE CRYSVITA CUBICIN - HNMC
CUBICIN RF - HNMC CUPRIMINE CUVITRU
CYRAMZA - HNMC CYSTADANE CYSTARAN
CYTOGAM - HNMC

D

DAKLINZA - HNMC DAKLINZA DALIRESP - HNMC
DARAPRIM DARZALEX - HNMC DAURISMO (pending P&T approval)
DAYTRANA DDAVP DELSTRIGO
DESFERAL DESOXYN - HNCA DESOXYN
DEXILANT DEXTROSE (IV) - HNMC Diabetic Test Strip Quantity Limit - Not Receiving Insulin - HNMC
DIACOMIT DIDREX - HNCA DIDREX
DIETHYLPROPION HCL - HNCA DIETHYLPROPION HCL - HNMC DOLOPHINE - HNMC
DOPTELET DORYX DORYX MPC
DUEXIS DUPIXENT DUPIXENT (pending P&T approval)
DUROLANE - HNCA DUROLANE DUZALLO
DYANAVEL XR DYSPORT

E

EDECRIN EDEX EDLUAR
EGRIFTA ELAPRASE ELELYSO
ELIDEL ELIGARD - HNMC EMBEDA
EMEND - HNMC EMFLAZA EMGALITY (pending P&T approval)
EMPLICITI ENBREL - HNMC ENBREL (pending P&T approval)
ENBREL ENDARI ENDOMETRIN
ENSTILAR ENTRESTO ENTYVIO - HNMC
ENTYVIO (pending P&T approval) ENTYVIO ENVARSUS XR
EPCLUSA - HNMC EPCLUSA EPIDIOLEX
EPIDUO FORTE EPIPEN 2-PAK - HNMC EPIPEN 2-PAK
EPIPEN-JR 2-PAK - HNMC EPIPEN-JR 2-PAK EPOGEN
ERBITUX ERLEADA ESBRIET
ESOMEPRAZOLE STRONTIUM EUCRISA EUFLEXXA - HNCA
EUFLEXXA EVZIO EXFORGE - HNMC
EXFORGE HCT - HNMC EXJADE EXONDYS 51
EXTAVIA - HNMC EXTAVIA EYLEA

F

FABRAZYME FANAPT FARXIGA - HNMC
FARYDAK FASENRA FENTORA
FERRIPROX FETZIMA FIRAZYR
FIRDAPSE (pending P&T approval) FIRMAGON - HNMC FLEBOGAMMA DIF
FLOLAN FOLLISTIM AQ FOLOTYN - HNMC
FORFIVO XL Formulary Exceptions FORTAMET
FORTEO (Exchange Plans) FORTEO (Non-Exchange Plans) FOSAMAX PLUS D
FOSRENOL FRAGMIN FROVA
FULPHILA (pending P&T approval) FUSILEV FUZEON
FYCOMPA

G

GABLOFEN - HNMC GALAFOLD GAMASTAN S/D
GAMIFANT (pending P&T approval) GAMMAGARD LIQUID GAMMAGARD S/D IGA LESS THAN 1MCG/ML
GAMMAKED GAMMAPLEX GAMUNEX-C
GANIRELIX ACETATE GATTEX GAZYVA - HNMC
GEL-ONE - HNCA GEL-ONE GELSYN-3 - HNCA
GELSYN-3 GENOTROPIN - HNMC GENOTROPIN
GENVISC 850 - HNCA GENVISC 850 GIAZO
GILENYA GILOTRIF GLASSIA
GLATOPA - HNMC GLATOPA GLEEVEC
GLUMETZA GLYXAMBI - HNMC GOCOVRI
GOCOVRI (pending P&T approval) GOLYTELY GONAL-F
GONAL-F RFF GONITRO GRALISE
GRANIX - HNMC GRANIX GRASTEK

H

H.P. ACTHAR HAEGARDA HALAVEN
HARVONI - HNMC HARVONI HEMLIBRA (pending P&T approval)
HEPSERA - HNMC HERCEPTIN HETLIOZ
HIZENTRA HUMAN CHORIONIC GONADOTROPIN Human Growth Hormone - HNMC
Human Growth Hormone HUMATROPE - HNMC HUMATROPE
HUMIRA - HNMC HUMIRA (pending P&T approval) HUMIRA
HYALGAN - HNCA HYALGAN HYMOVIS - HNCA
HYMOVIS HYQVIA HYSINGLA ER - HNMC
HYSINGLA ER

I

IBRANCE ICLUSIG IDHIFA
ILARIS ILUMYA ILUMYA (pending P&T approval)
ILUVIEN IMBRUVICA IMITREX
IMITREX INJECTION Immune Globulin (IVIG) Immunization Coverage - HNMC
INCRELEX INFLECTRA - HNMC INFLECTRA (pending P&T approval)
INFLECTRA INGREZZA INLYTA
INTERMEZZO INTRALIPID - HNMC INTRAROSA
Intravenous Potassium Chloride - HNMC INVOKAMET - HNMC INVOKAMET XR - HNMC
INVOKANA - HNMC IRESSA ISTODAX (OVERFILL) - HNMC

J

JADENU JALYN JANUMET - HNMC
JANUMET XR - HNMC JANUVIA - HNMC JARDIANCE - HNMC
JENTADUETO - HNMC JENTADUETO XR - HNMC JEVTANA - HNMC
JUBLIA JUXTAPID JYNARQUE

K

KADCYLA KALBITOR KALYDECO
KAZANO - HNMC KEPPRA XR - HNMC KERYDIN
KEVEYIS KEVZARA - HNMC KEVZARA (pending P&T approval)
KEVZARA KEYTRUDA KEYTRUDA (pending P&T approval)
KHEDEZLA KINERET - HNMC KINERET (pending P&T approval)
KINERET KISQALI KISQALI FEMARA
KITABIS PAK KOMBIGLYZE XR - HNMC KORLYM
KRINTAFEL KRINTAFEL (pending P&T approval) KRYSTEXXA
KYMRIAH KYNAMRO KYPROLIS - HNMC
KYTRIL

L

LACTATED RINGERS - HNMC LAMICTAL ODT LAMICTAL XR - HNMC
LAMICTAL XR LARTRUVO LATUDA
LAZANDA LEMTRADA - HNMC LEMTRADA
LENVIMA LEUCOVORIN CALCIUM LEUKINE - HNMC
LEUKINE LEVITRA - HNCA LEVITRA
LEVORPHANOL TARTRATE - HNMC LEVORPHANOL TARTRATE LIBTAYO
LIDODERM LINDANE - HNMC LINZESS - HNMC
LIORESAL INTRATHECAL - HNMC LOKELMA LOMAIRA - HNCA
LOMAIRA - HNMC LONSURF LORBRENA (pending P&T approval)
LOTRONEX LOVENOX LUCEMYRA
LUCENTIS LUMIZYME LUMOXITI
LUPANETA PACK - HNMC LUPRON DEPOT - HNMC LUPRON DEPOT-PED - HNMC
LUTATHERA - HNMC LUXTURNA LUZU
LYNPARZA LYNPARZA (pending P&T approval) LYRICA

M

MACUGEN MAKENA MARINOL
MARQIBO MAVYRET - HNMC MAVYRET
MAXALT MAXALT-MLT MEGACE ES - HNMC
MEKINIST MEKTOVI MENOPUR
MEPSEVII MESTINON MINASTRIN 24 FE
MIRCERA - HNMC MIRCERA MIRVASO
MODERIBA - HNMC MODERIBA MONOVISC - HNCA
MONOVISC MORPHABOND ER - HNMC MORPHABOND ER
MORPHINE SULFATE - HNMC MOVANTIK - HNMC MOXIDECTIN
MOZOBIL MULPLETA (pending P&T approval) MUSE
MVASI MYALEPT MYDAYIS
MYLOTARG MYOBLOC MYORISAN
MYTESI

N

NAGLAZYME NAMENDA XR NAMZARIC
NARCAN Narcotic Quantity Limits - HNCA Narcotic Quantity Limits - HNMC
NATESTO NATPARA NEO-SYNALAR KIT
NERLYNX NESINA - HNMC NESINA
NEULASTA NEULASTA (pending P&T approval) NEUPOGEN - HNMC
NEUPOGEN NEXIUM NINLARO
NITYR No Coverage Criteria - Off-Label Uses - HNMC NOCDURNA
NOCTIVA NORDITROPIN - HNMC NORDITROPIN
NORTHERA NOVANTRONE - HNMC NOVANTRONE
NOVAREL NPLATE NUCALA
NUEDEXTA NULOJIX - HNMC NUPLAZID
NUTRILIPID - HNMC NUTROPIN AQ - HNMC NUTROPIN AQ
NUVESSA NUVIGIL NUZYRA (pending P&T approval)

O

OCALIVA OCREVUS - HNMC OCREVUS
OCTAGAM ODACTRA ODEFSEY - HNMC
ODEFSEY ODOMZO OFEV
Off-Label Uses OGIVRI OLUMIANT - HNMC
OLUMIANT (pending P&T approval) OLYSIO - HNMC OLYSIO
OMNITROPE - HNMC OMNITROPE ONCASPAR
ONEXTON ONFI - HNMC ONGLYZA - HNMC
ONIVYDE - HNMC ONMEL ONPATTRO
ONZETRA XSAIL OPDIVO - HNMC Opioid Analgesics - HNMC
OPSUMIT ORACEA ORALAIR
ORENCIA - HNMC ORENCIA (pending P&T approval) ORENCIA
ORENITRAM ORFADIN ORILISSA
ORKAMBI ORTHOVISC - HNCA ORTHOVISC
OSENI - HNMC OSMOLEX ER (pending P&T approval) OSMOPREP
OSPHENA OTEZLA - HNMC OTEZLA (pending P&T approval)
OTEZLA OTREXUP OVIDREL
OXERVATE (pending P&T approval) OXTELLAR XR OXYCONTIN - HNMC
OZEMPIC - HNCA OZEMPIC - HNMC OZURDEX

P

PALYNZIQ PANRETIN PARSABIV - HNMC
PEGASYS PEGINTRON PENNSAID 2%
PHENDIMETRAZINE TARTRATE - HNMC PLEGRIDY PLENVU
POMALYST PORTRAZZA - HNMC POTELIGEO
PRALUENT PREGNYL W/DILUENT BENZYLALCOHOL/NACL PREPOPIK
PRESTALIA PREVACID SOLUTAB PREVYMIS
PRILOSEC PRISTIQ PRIVIGEN
PROBUPHINE IMPLANT KIT - HNCA PROCRIT PROLASTIN-C
PROLIA PROLIA (pending P&T approval) PROMACTA
PROVENGE PROVIGIL PURIXAN

Q

QBREXZA QSYMIA - HNCA QSYMIA - HNMC
QTERN (pending P&T approval) QUALAQUIN Quantity Limit Overrides - HNMC
QUDEXY XR QUILLICHEW ER QUILLIVANT XR

R

RADICAVA RAGWITEK RANEXA
RASUVO RAVICTI RAYALDEE
RAYOS RAZADYNE - HNMC RAZADYNE ER - HNMC
RAZADYNE ER RAZADYNE REBETOL - HNMC
REBETOL REBIF - HNMC REBIF
RECLAST REGIMEX - HNCA REGIMEX - HNMC
REGRANEX - HNMC RELISTOR - HNMC RELISTOR
RELPAX REMICADE - HNMC REMICADE (pending P&T approval)
REMICADE REMODULIN RENAGEL
RENFLEXIS - HNMC RENFLEXIS (pending P&T approval) RENFLEXIS
RENVELA REPATHA - HNMC REPATHA
Request for Medically Necessary Drug not on the PDL - HNMC RESTASIS RETACRIT
RETISERT REVATIO REVLIMID
REXULTI RHOFADE RHOPRESSA
RIBASPHERE - HNMC RIBASPHERE RIBAPAK - HNMC RIBASPHERE RIBAPAK
RIBASPHERE RITUXAN - HNMC RITUXAN (pending P&T approval)
RITUXAN HYCELA - HNMC RITUXAN HYCELA RITUXAN
ROZEREM RUBRACA RUCONEST
RYDAPT RYTARY

S

SABRIL - HNMC SAIZEN - HNMC SAIZEN
SAMSCA SANCUSO SANDOSTATIN
SANDOSTATIN LAR DEPOT SAPHRIS SAVELLA
SAXENDA - HNCA SAXENDA - HNMC SEEBRI NEOHALER
SEGLUROMET - HNMC SENSIPAR - HNMC SERNIVO
SEROQUEL XR SEROSTIM - HNMC SEROSTIM
SEYSARA (pending P&T approval) SIGNIFOR SIGNIFOR LAR
SILENOR SILIQ - HNMC SILIQ (pending P&T approval)
SILIQ SIMPONI - HNMC SIMPONI (pending P&T approval)
SIMPONI ARIA - HNMC SIMPONI ARIA (pending P&T approval) SIMPONI ARIA
SIMPONI SITAVIG SODIUM CHLORIDE - HNMC
SOLARAZE SOLIQUA 100/33 - HNCA SOLIQUA 100/33 - HNMC
SOLIRIS SOLODYN SOLOSEC
SOMATULINE DEPOT SOMAVERT SOOLANTRA
SORIATANE - HNMC SOVALDI - HNMC SOVALDI
SPINRAZA SPORANOX SPRITAM
SPRYCEL SPRYCEL (pending P&T approval) STAXYN - HNCA
STAXYN STEGLATRO - HNMC STEGLATRO
STEGLUJAN - HNMC STEGLUJAN (pending P&T approval) STELARA - HNMC
STELARA (pending P&T approval) STELARA STENDRA - HNCA
STENDRA Step Therapy - HNMC Step Therapy
STIMATE STIOLTO RESPIMAT - HNMC STIVARGA
STRATTERA - HNMC STRENSIQ SUBLOCADE - HNCA
SUBOXONE - HNCA SUBOXONE SUBSYS
SUBUTEX SUMAVEL DOSEPRO SUPARTZ FX - HNCA
SUPARTZ FX SUPPRELIN LA - HNMC SUSTOL
SUTENT SYLATRON SYMDEKO
SYMLIN - HNCA SYMLIN SYMPROIC
SYMTUZA - HNMC SYMTUZA SYNAGIS
SYNAREL - HNMC SYNDROS SYNJARDY - HNMC
SYNJARDY XR - HNMC SYNRIBO SYNVISC - HNCA
SYNVISC ONE - HNCA SYNVISC ONE SYNVISC
SYPRINE

T

TACLONEX TAFINLAR TAGRISSO
TAKHZYRO TALTZ - HNMC TALTZ (pending P&T approval)
TALTZ TALZENNA (pending P&T approval) TANZEUM - HNMC
TANZEUM TARCEVA TARGRETIN
TASIGNA TAVALISSE TAYTULLA
TAZORAC - HNMC TECFIDERA TECHNIVIE - HNMC
TECHNIVIE TEGSEDI (pending P&T approval) TEKTURNA
TEKTURNA HCT TENUATE TESTIM
TESTOPEL TESTOSTERONE TEV-TROPIN - HNMC
THYROGEN - HNMC TIBSOVO TIVORBEX
TOBI TOBI PODHALER TOLAK
TORISEL - HNMC Total Parenteral Nutrition (TPN) and Intradialytic Parenteral Nutrition (IDPN) - HNMC TRADJENTA - HNMC
TREANDA - HNMC TRELEGY ELLIPTA - HNMC TRELSTAR
TREMFYA - HNMC TREMFYA (pending P&T approval) TREMFYA
TREXIMET TRIBENZOR - HNMC TRIBENZOR
TRINTELLIX - HNMC TRINTELLIX TRIPTODUR
TROGARZO TROKENDI XR TRULANCE
TRULICITY - HNCA TRULICITY - HNMC TRUXIMA (pending P&T approval)
TYKERB TYMLOS TYSABRI - HNMC
TYSABRI CD TYSABRI CD (pending P&T approval) TYSABRI MS
TYVASO

U

UCERIS ULTRAVATE UPTRAVI
UTIBRON NEOHALER - HNMC

V

VALCHLOR VALCYTE VANCOCIN HCL
VANTAS - HNMC VECAMYL VECTIBIX
VELETRI VELPHORO VELTASSA
VEMLIDY VENCLEXTA VENCLEXTA (pending P&T approval)
VENTAVIS VERZENIO VERZENIO (pending P&T approval)
VIAGRA - HNCA VIAGRA VIBERZI
VICTOZA - HNCA VICTOZA - HNMC VIDAZA
VIEKIRA PAK - HNMC VIEKIRA PAK VIEKIRA XR - HNMC
VIEKIRA XR VIIBRYD - HNMC VIIBRYD
VIMIZIM VIMOVO VIMPAT - HNMC
VISCO-3 - HNCA VISUDYNE VITRAKVI (pending P&T approval)
VIVLODEX VIZIMPRO VOGELXO
VOSEVI - HNMC VOSEVI VOTRIENT
VPRIV VRAYLAR VYTORIN
VYXEOS - HNMC VYZULTA

W

X

XADAGO XALKORI XARTEMIS XR
XATMEP XELJANZ - HNMC XELJANZ (pending P&T approval)
XELJANZ XR - HNMC XELJANZ XR (pending P&T approval) XELJANZ XR
XELJANZ XENICAL - HNCA XENICAL - HNMC
XEOMIN XEOMIN (pending P&T approval) XEPI
XERMELO XGEVA XGEVA (pending P&T approval)
XHANCE XIAFLEX XIFAXAN
XIGDUO XR - HNMC XIIDRA - HNMC XIIDRA
XIMINO XOFLUZA XOLAIR
XOSPATA (pending P&T approval) XTAMPZA ER - HNMC XTAMPZA ER
XTANDI XTANDI (pending P&T approval) XULTOPHY 100/3.6 - HNCA
XULTOPHY 100/3.6 - HNMC XYREM XYZAL

Y

YERVOY - HNMC YESCARTA YONDELIS
YONSA

Z

ZALTRAP ZARXIO - HNMC ZARXIO
ZAVESCA ZEGERID ZEJULA
ZELBORAF ZEMAIRA ZEMBRACE SYMTOUCH
ZEMPLAR - HNMC ZENATANE ZEPATIER - HNMC
ZEPATIER ZILRETTA ZINBRYTA - HNMC
ZINBRYTA ZINPLAVA ZIPSOR
ZOFRAN ZOHYDRO ER - HNMC ZOHYDRO ER
ZOLADEX - HNMC ZOLINZA ZOLPIMIST
ZOMACTON - HNMC ZOMACTON ZOMETA
ZOMIG ZORBTIVE - HNMC ZORBTIVE
ZORTRESS ZORVOLEX ZTLIDO
ZUBSOLV - HNCA ZUBSOLV ZUPLENZ - HNMC
ZUPLENZ ZURAMPIC ZYDELIG
ZYFLO ZYFLO CR ZYKADIA
ZYTIGA

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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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