If a prescription drug is not covered, or there are coverage restrictions or limits on a drug, you may contact us and request a coverage determination.
You can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested.
To request an exception, you or your prescriber can email, fax or mail a Coverage Determination Request Form to the contact information listed below. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse 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 members are receiving the correct drug combined with the best value for their medical condition.
To request prior authorization, you or your prescriber can email, fax or mail a Coverage Determination Request Form to the contact information listed below. 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 your condition and/or would cause you to have harmful medical effects.
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. A coverage determination can also be requested by calling Customer Service. If a request is sent by email, be sure to include your name, Health Net member ID number and telephone number, as well as the details of the request. The Member Medicare Part D Coverage Determination Request Form can be used as a guide of information to include. With the request, we require a supporting statement from your prescriber explaining why a particular drug is medically necessary for your 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 after we have received your prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered. If we deny the 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.
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.
To submit the form online, Please click here
Members: Contact us
Prescribers: 1-800-867-6564
Calls received after hours will be handled by our automated phone system and a Health Net representative will return your call on the next business day.
To protect personal health information and privacy, Health Net has a Secure Messaging Center to make corresponding with us safe and efficient. Please do not send emails to Health Net using your personal email account. To access Secure Messaging, you must be registered on HealthNet.com.
Log in to the Secure Messaging Center. Select Compose. You will be prompted to enter an email address in the To: field. Paste medicaredeterminations@healthnet.com in the To: field. Please attach any supporting or relevant documents to your secure email message.
Health Net Pharmacy Department
Attn: Prior Authorizations
PO Box 419069
Rancho Cordova, California 95741-9069
1-800-977-8226
For more information about coverage determinations, exceptions and prior authorization, refer to the section, Your Part D prescription drugs: How to ask for a coverage decision or make an appeal, in your Evidence of Coverage (EOC).
Information last updated 10-10-2017
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