Medicare Pharmacy FAQs

1. How do I know if my drugs are covered?

2. What if my drug is not on the Health Net Medicare Part D Formulary?

3. How do I request an exception to the Health Net Medicare Part D Formulary?

4. How do I fill a prescription through Health Net's mail order pharmacy?

5. How do I fill a prescription at an out-of-network pharmacy?

6. How do I submit a paper claim?

7. How can I submit an appeal or complaint?

8. What is the Health Net Medicare Part D Transition Program?


1. How do I know if my drugs are covered?

You can search our Medicare Part D Formularies on the Drug Lists page. When it comes to benefits and prescription drugs, we're constantly re-evaluating our customer's needs. We know which conditions are most likely to affect you, and the drugs you're most likely to need. That's why we've taken such care to ensure that our prescription drug plan for Medicare offers coverage for so many commonly prescribed, brand name and generic drugs.

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2. What if my drug is not on the Health Net Medicare Part D Formulary?

If you learn that Health Net does not cover your drug, you have two options:

  • You can talk to your prescriber about switching your prescription to a covered drug.
  • You can ask Health Net to make an exception and cover your drug.

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3. How do I request a coverage determination or an exception to the Health Net Medicare Part D Formulary?

There are several types of coverage determinations and exceptions that you can request. For more information about coverage determinations and exceptions, visit our Coverage Determinations pages:

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4. How do I fill a prescription through Health Net's mail order pharmacy?

View our Mail Order Overview page for general information about ordering your prescriptions by mail.

You can use the Health Net mail order pharmacy to fill prescriptions for most maintenance drugs that are on the Health Net Medicare Part D formulary. Some drugs may not be available through the mail order pharmacy. A maintenance drug is any prescription drug needed to treat a chronic or long-term condition.

When you order prescription drugs by mail, you may not order more than a 90-day supply of the drug at a time.

You are not required to use Health Net's mail order pharmacy to obtain an extended supply of your drugs. Instead, you have the option of using a retail pharmacy in Health Net's network to obtain an extended supply of your drugs. Some network retail pharmacies, however, will only dispense a maximum 30-day supply of drugs. To find out if your pharmacy will dispense an extended supply, check your pharmacy directory or ask your pharmacy.

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5. How do I fill a prescription at an out-of-network pharmacy?

Before you use an out-of-network pharmacy, contact Customer Service to check if there is a network pharmacy in the area where you can fill your prescription.

If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

Generally, we will cover your prescription at an out-of-network pharmacy if you cannot reasonably be expected to obtain your drugs at a network pharmacy and when such access is not routine. This may include:

  • If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance or no network pharmacies that provide service 24-hours a day, seven days a week.
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy (including high cost and unique drugs).
  • If you are getting a vaccine that is medically necessary but not covered by Medicare Part B or other covered drugs that are administered in your doctor's office.
  • If you need a prescription filled that is related to care for a medical emergency or urgent care.
  • If you are evacuated or otherwise displaced from your home because of a Federal disaster or other public health emergency declaration.

If you go to an out-of-network pharmacy, you may have to pay the full cost of your�drug rather than paying just your copayment. You can ask us to reimburse you for our share of the cost by submitting a claim. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy because any amount you pay will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described below.

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6. How do I submit a paper claim?

Generally, when you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription and submit your claim and your prescription receipt to us. For more information on submitting a claim, visit our Claims Reimbursement pages:

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7. How can I submit an appeal or complaint?

You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "Grievances" are the two different types of complaints you can make. Which one you make depends on your situation. Appeals and grievances are discussed in the Evidence of Coverage. For more information, visit our Appeals and Grievance pages:

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8. What is the Health Net Medicare Part D Transition Program?

The Health Net Medicare Part D Transition Program allows eligible Health Net Medicare Part D members to receive a temporary supply of drugs to avoid disruption of therapy.

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