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Pharmacy Information - Medicare Plans

Drug Information for Medicare Plans


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.

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Health Net Seniority Plus (Employer HMO)

Step Therapy Criteria

Medicare Part D Step Therapy Criteria

Formulary Change Notice

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.

Medicare Part D Negative Formulary Changes


You can look for network pharmacies with our Find a Pharmacy tool.

Information last updated 01-09-2018

Prior Authorization

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 or providers may request a coverage determination.


Members or providers can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested. An exception can be requested to:

  • Cover a 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.
  • Waive coverage restrictions or limits on a drug. For example, Health Net may limit the amount of a drug that will be covered. If a drug has a quantity limit, members can ask us to waive the limit and cover more.
  • Cover a drug at a lower tier. Drugs on the preferred brand tier and Specialty tier may not be 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.


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.


To request an exception or to obtain prior authorization, members or 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 (24 hours for Medi-Cal covered drugs) 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, members can appeal our decision. Information on how to file an appeal is included with the denial notification.


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.



Prescribers: 1-800-867-6564

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 a 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

Log in to the Secure Messaging Center. Select Compose. You will be prompted to enter an email address in the To: field. Paste in the To: field. Please attach any supporting or relevant documents to your secure email message.


Health Net Prior Authorization Department
PO Box 419069
Rancho Cordova, CA 95741-9069




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.


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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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