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Drug List for Medicare Advantage Members

Drug and Pharmacy Information

2018 FORMULARIES

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.

Plan Printable PDF
Health Net Seniority Plus (Employer HMO)

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

2018 PHARMACY DIRECTORIES

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

MEDICATION THERAPY MANAGEMENT

Our Medication Therapy Management (MTM) program is offered at no cost to eligible members. The MTM program helps members learn how to get the most from their medication.


Who is eligible?

To be eligible for the MTM program, members must:

  • Have three or more of the following diseases:
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Depression
    • Diabetes
    • End-Stage Renal Disease (ESRD)
    • High cholesterol
    • Osteoporosis
  • Take eight or more drugs that treat chronic conditions
  • Have expected drug costs of at least $3,967 per year

How do I enroll?

All eligible members are automatically enrolled in the program. Though this program is not called a benefit, it's offered at no charge to our members.

Once members are enrolled in the program, a pharmacist reviews each member's pharmacy records. Members get a Welcome letter about any issues found by the pharmacist. The Welcome letter invites members to call a pharmacist to ask questions about their drugs. The Welcome letter also tells members how to call and ask for a comprehensive medication review (CMR).


What is a Comprehensive Medication Review?

A CMR is a complete review of all of the drugs each member takes. This includes prescription and over-the-counter drugs, vitamins and herbal supplements. A CMR takes about 30 - 60 minutes. Pharmacists work with members to create a plan for any problems found in the review. Pharmacists may discuss any problems found during the CMR with doctors or other prescribers when needed. A member can call us and ask for a CMR or a pharmacist may call a member to offer a CMR.

As part of a CMR, pharmacists create a personal list of medications for members. Members can also print and fill out a blank personal medication list (PDF) at any time.


Follow up review

Every three months or so, our pharmacists review every MTM members’ pharmacy records for any new problems. After each review, we send a letter to the member that lists any issues. The letter also suggests ways to help improve medication use.

To find out more about our MTM program or to get copies of MTM documents, you may contact us .

Medicare Part D Transition Program

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.


For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.


Level of Care Changes

If your level of care changes, we will cover a transition supply of your drugs. A level of care change happens when you are released from a hospital. It also happens when you move to or from a long-term care facility.

  • If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 30-day supply.
  • If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow refills to provide up to a total of a 31-day supply.

Transition Letter

You will be sent a transition letter when we cover a transition supply of your drug. The transition letter is member-specific and is available for free in another format or language upon request. To ask for the letter in another format or language, please contact us .

EXPLANATION OF BENEFITS

When you use your Part D prescription drug benefits, we will send you an Explanation of Benefits to help you understand and keep track of payments for your Part D prescription drugs. The Explanation of Benefits is member specific and is available for free in another format or language upon request.

Out-of-Network Pharmacies

With our nationwide network of pharmacies, it's easy to get your prescriptions filled using your pharmacy benefits. However, we understand you may not always be able to use a network pharmacy. We may cover prescriptions filled at an out-of-network pharmacy if:

  • There is no network pharmacy that is close to you and open.
  • You need a drug that you can’t get at a network pharmacy close to you.
  • You need a drug for emergency or urgent medical care.
  • You must leave your home due to a federal disaster or other public health emergency.

Before you have your prescription filled in these situations, contact us to check if there is a network pharmacy in your area that can fill your prescription.

Pharmacy Claims Reimbursement

In most cases, your claim will be automatically submitted when you have your prescription filled at a network pharmacy. However, if you go to an out-of-network pharmacy, they may not submit the claim directly to us. In these cases, you must pay the full cost of your prescription upon receipt. You may then submit a Medicare Prescription Claim Form to request a reimbursement of our share of the cost.

Submitting a Claim

  • Complete the Medicare Prescription Claim Form .
  • Attach the original copy of your prescription receipts to the form. If you do not have the original receipt, a copy can be obtained from the dispensing pharmacy. Cash register receipts may not be used when submitting a claim.

Mail the completed form and receipts to the address listed on the form. Once we receive your claim, we will mail our determination with a check, if applicable, to you within 14 days.

Refer to your Evidence of Coverage for specific information about drug coverage and limitations. If you have questions about this process, please contact us .

Information last updated 12-20-2017

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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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For more information, please review carefully the disclosure form for your plan. It includes additional terms and information on certain exclusions and limitations.

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You may request copies of the forms referenced above for your health plan by: closing this window and clicking on Contact Us at the top of any web page.
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