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.
The initial decision made by Health Net is the starting point for dealing with requests you may have about your coverage or payment for your care. When Health Net makes an initial decision, we are giving our interpretation of how the benefits and services that are covered apply to your specific situation. With this decision, we inform you whether we will provide the medical care or service you request, or pay for a service you have already received. (This initial decision is sometimes called an organization determination.)
A decision about payment for care you already received can take up to 30 calendar days. However, if more information is required to make an informed decision, Health Net can take up to 30 more days. You will be informed in writing when Health Net makes a decision.
A decision about whether we will cover medical care that you have not yet received can be a "standard" organization determination that is made within the standard timeframe (typically within 14 days) or it can be a "fast" organization determination that is made more quickly (typically within 72 hours). A fast decision is sometimes called an expedited organization determination.
You, your doctor or your appointed representative can ask for a fast decision only if you or your doctor believe that waiting for a standard decision could seriously harm your health or your ability to function. If your request for a fast decision is approved, Health Net must make its decision as quickly as your health condition might require, but no later than 72 hours of receiving your request. To request a fast decision, call Customer Service. You can also mail or fax a written request to Health Net at the address below. There are no required forms. Be sure to ask for a fast, expedited, or 72-hour review.
To ask for a standard decision, you, your doctor, or your appointed representative can mail or fax a written request to the address below. There are no required forms.
If we deny your request (this is sometimes called an adverse organization determination), you can appeal our decision.
If your prescriber or pharmacist tells you that a prescription drug is not covered, or there are coverage restrictions or limits on a drug, you may call Customer Service and request a coverage determination.
You can request a coverage determination to make an exception to our coverage rules. There are several types of exceptions you can request.
Generally, Health Net will only approve your request for an exception if preferred alternative drugs or utilization restrictions would not be as effective in treating your condition and/or would cause you to have harmful medical effects.
Some drugs require prior authorization. This means that you must receive approval from Health Net before the drug will be covered. The prior authorization process ensures you are receiving the correct drug combined with the best value for your medical condition.
To request an exception or to obtain prior authorization, you or your prescriber can email, fax or mail a coverage determination request to the contact information listed below. You or your prescriber may also call Customer Service to request a coverage determination. If you email your request, be sure to include your name, Health Net member ID number and telephone number, as well as the details of your request. The Member Medicare Part D Coverage Determination Request Form can be used as a guide of information to include. We also need a supporting statement from your prescriber explaining why a particular drug is medically necessary for your condition.
Once we receive your 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 after we have received your prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered under your Medicare Part D benefit. If we deny your request (this is sometimes called an adverse coverage determination), you can appeal our decision. Information on how to file an appeal is included with the denial notification.
Standard vs. Fast Decision
If waiting up to 72 hours for a "standard" decision could seriously harm your health or your ability to function, you or your prescriber 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 you have not already received. If a request for a fast decision is received, we must make our decision and respond within 24 hours. To request a fast decision, contact us by fax or by calling Customer Service. We will make our decision and respond to all requests as quickly as your health condition requires.
For more information about coverage determinations, exceptions and prior authorization, you may refer to the sections of the Evidence of Coverage (EOC) for your plan listed below, or you may call Customer Service. The fact that a drug is listed on the formulary does not guarantee that it will be prescribed for you for a particular medical condition.
|Plan Name||Coverage Determinations EOC Section|
|Health Net Healthy Heart (PPO), Health Net Ruby (HMO), Health Net Violet (PPO), Health Net Jade (HMO-SNP)||Chapter 9, section 4|
To protect your personal health information and privacy, please do not send emails to Health Net using your 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 www.healthnet.com.
Login to the Secure Messaging Center. Select Compose. You will be prompted to enter an email address in the To: field. Paste email@example.com in the To: field. Please attach any supporting or relevant documents to your secure email message.
Health Net Pharmacy Department (for Drugs)
13221 SW 68th Parkway, Suite 200
Tigard, OR 97223
Members: Contact Customer Service
Calls received after hours will be handled by our automated phone system and a Health Net representative will call you back on the next business day.
Link to the Centers for Medicare and Medicaid Services (CMS) Request for Medicare Prescription Drug Determination Form (for use by enrollees).
Information last updated 12/13/2012