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.
Health Net's Quality Assurance programs include real-time review of prescription claims, as well as a review of prescription claims history. This ensures our members are receiving safe and appropriate drugs. The programs include reviews that focus on reducing drug errors and adverse drug interactions. These reviews are especially important for members who take more than one drug, use more than one pharmacy, or have more than one provider who prescribes their drugs.
For members who are taking drugs that are either not on Health Net's Medicare Part D Formulary or are subject to restrictions or limitations.
Under Health Net's transition program, members are given access to non-formulary drugs. This includes Part D drugs that are not on the Health Net Medicare Part D formulary, as well as drugs that are on the formulary with a limit or restriction (not based on safety).
The transition program is designed to ensure continuity of care for new members, existing members who may be subject to formulary changes, and members who experience a level of care change. The program also allows members in long-term care facilities access to a temporary transition supply of drugs.
If you are a new member, you may be taking drugs that are not on the formulary or you may be taking drugs that are on the formulary but have restrictions or limits. For example, you may need a prior authorization from us before your prescription can be filled. In these cases, you should talk to your doctor or other prescriber to decide if you should change to drugs that we cover or request an exception so we will cover the drugs you take. While you talk to your doctor or other prescriber to determine the right course of action for you, we may cover your drugs in certain cases during the first 90 days you are a member of our plan. We will cover a one-time temporary 30-day transition supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. If your prescription is written for less than a 30-day transition supply, refills for up to a total of a 30-day supply will be covered. This may also apply if you are a renewing member and experience a change in the formulary at the beginning of the contract year.
If you are a new member and are a resident of a long-term care facility, we will cover a temporary 34-day transition supply (unless you have a prescription written for fewer days). We will allow you to refill your prescription until we have provided you with a 102-day transition supply (unless you have a prescription written for fewer days).
If you are a resident of a long-term care facility and past the first 90 days of membership in our plan and you need drugs that are not on the formulary or are on the formulary with certain limits or restrictions (not based on safety), we will cover up to a 34-day emergency supply of your drugs (unless you have a prescription written for fewer days) while you seek an exception. If your prescription is written for less than a 34-day transition supply, refills for up to a total of a 34-day supply will be covered.
Level of Care Changes
If you experience a change in level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility.
We understand that there are other circumstances when an override may be granted. These situations are managed on a case-by-case basis through communication between the dispensing pharmacy and Health Net.
You will be sent a transition letter to notify you that Health Net has covered a transition supply of your drug because the drug is not on the Health Net Medicare Part D formulary, or to notify you that your drug is on the formulary but is subject to restrictions or limits.
The transition letter is member-specific and is available for free in another format or language upon request. To request this document in another format or language, please call Customer Service.
Participation in Health Net's Medication Therapy Management (MTM) program offers members at high risk for prescription drug-related problems a full range of
services and an integrated approach to safe and effective treatments that lead to positive medical outcomes at economic value. This approach involves many
people, from the members themselves to their caregivers, pharmacists, prescribers, health educators, and care coordinators. Prospective MTM program
candidates must meet all three of the following criteria:
Although this program is not considered a benefit, all qualifying members are automatically enrolled free of cost. Qualifying members may opt-out at any time.
A team of pharmacists and physicians developed the MTM program for Health Net to help us provide our members better care by ensuring that they use the appropriate drugs to treat their multiple conditions and by identifying their possible drug-related issues. For each program participant, Health Net pharmacists and other clinicians provide structured stepped interventions and develop plans with the members and/or their caregivers designed to get the most benefit from the prescription drugs they take.
RxCellent Care is an MTM program management tool and software developed by Health Net pharmacists to help them identify drug-related issues and track the outcomes of all interventions made. The pharmacists use RxCellent Care to scan a member's pharmacy claims history and then evaluate the member's drug profile to determine if changes are needed to improve therapy and minimize potential for adverse reactions. RxCellent Care helps the pharmacists review for drug interaction risks, drug dosing, and conflicting or overlapping therapeutic effects.
The pharmacists then send letters with educational materials to each member recommending alternative drugs or dosing, discontinuing drugs, or other appropriate therapy modifications. They consult the member's treating physicians about medical issues raised in the review, and, as needed, discuss treatment plans with the prescribers, including approval to modify drug therapy, if appropriate.
For more information about the MTM program, please call Customer Service.
Health Net conducts drug utilization reviews when your pharmacy fills your prescription. When a pharmacy submits a prescription claim at the point-of-sale, the claim may be electronically reviewed for one or more of the following:
All pharmacies in the Health Net Pharmacy Network are contractually obligated to comply with the National Council for Prescription Drug Programs (NCPDP) pharmacy claim processing standards, which include drug utilization review edits such as those described above. In accordance with contractual requirements and State Boards of Pharmacy rules and regulations, pharmacies must respond to any alerts identified by these electronic edits and maintain an up-to-date patient profile including demographic and allergy information.
In addition to the concurrent review described above, Health Net regularly reviews prescription claims history to:
In addition to the NCPDP electronic edits, Health Net has other coverage restrictions to help ensure safe and appropriate drug utilization. These restrictions may include:
You can find out if your drug is subject to these additional requirements or limits by looking in the Health Net Medicare Part D Formulary.
Health Net's Quality Assurance program includes an ongoing Chronic Care Improvement program with established criteria for participation in the program. Methods for identifying and monitoring members with chronic conditions who would benefit from participating in the program are clearly defined. Analysis and evaluation of the chronic care program cover the chronic illnesses of the members, types and scope of services offered, and description of the measures used to assess program performance and results.
Development of the Chronic Care Improvement program considers chronic care initiatives already used by Health Net's disease management program. Health Net's disease management initiatives support the physician/ practitioner relationship with the patient and the plan of care emphasizing prevention of complications through the use of evidence-based practice guidelines, patient self-management strategies and evaluate clinical, financial and quality of life outcomes on an ongoing basis with the goal of improving overall health status.
Annually, Health Net conducts quality improvement projects that include the entire organization focusing on clinical and non-clinical areas giving priority to quality performance. These projects engage in activities and efforts to have a favorable effect on health improvement and member satisfaction. Formal periodic evaluation is performed to review the effectiveness of quality improvement activities implemented. Consequently, each project is assessed on performance using objective quality indicators based on current clinical knowledge or health services research. Outcomes are measured through changes in health status, functional status and member satisfaction.
Information last updated 09/27/2012