Coverage Determinations for Drugs - Exceptions and Prior Authorization
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.
- You can ask us to cover your drug even if it is not on our formulary. Please note that if we grant a request to cover a drug that is not on our formulary, the drug will be available for the Non-preferred Brand tier copayment. The drug is not eligible for an exception for payment at a lower tier.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Health Net may limit the amount of the drug that will be covered. If a drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to make an exception and cover your drug at a lower tier. Drugs on the Preferred Brand tier and Specialty tier are not eligible for an exception for payment at a lower tier. If your plan uses the Value formulary, brand drugs on the Preferred Brand tier and Specialty tier are not eligible for an exception for payment at a lower tier.
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.
- PRIOR AUTHORIZATION – PHARMACY
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.
- COVERAGE DETERMINATION PROCESS
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 (pdf) 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.
- STANDARD & FAST DECISIONS
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.
- CONTACT INFORMATION
Members: Contact Customer Service
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 firstname.lastname@example.org in the To: field. Please attach any supporting or relevant documents to your secure email message.
Health Net Pharmacy Department
PO Box 9103
Van Nuys, CA 91409-9103
- MORE INFORMATION
For more information about coverage determinations, exceptions and prior authorization, refer to the sections of the Evidence of Coverage (EOC) for the plans listed below, or call Customer Service. The fact that a drug is listed on the formulary does not guarantee that it will be prescribed for a particular medical condition.
Plan Name Coverage Determinations EOC Section Health Net Healthy Heart (HMO), Health Net Seniority Plus Ruby (HMO), Health Net Ruby Select (HMO), Health Net Gold Select (HMO), Health Net Jade (HMO SNP), and Health Net Violet (PPO) Chapter 9, section 6 Health Net Amber (HMO SNP) Chapter 9, section 7