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Pharmacy Benefits for Individual and Family Plan Members

Pharmacy Benefits

Understanding My Pharmacy Benefits Download (pdf)

We created this Pharmacy Benefits Member Guide to make it easier for you to understand and get the most from your pharmacy benefit coverage. It will also give you important cost-saving options. Since some plans may differ from others, you'll want to Log in to access your coverage documents for details about your specific plan benefits.


TIERED BENEFIT PLANS

Our two- and three-tier plans give you both generic and brand name prescription drug coverage. You get easy-to-use pharmacy programs that offer the convenience you want with the value you're looking for.

Some plans may also have a Specialty Tier, which is covered under the pharmacy benefit. Specialty Tier drugs will usually be provided by a specialty pharmacy identified by us. Most of these drugs require prior authorization. Please refer to your plan documents and our Recomended Drug List for specific coverage, copay and tier information.

ABOUT PLAN DEDUCTIBLES

Some plans have an annual deductible – the amount you pay before your plan benefits will pay for covered services. If your plan has an annual deductible, it means you pay:

  • The full price of your prescription until you reach the deductible amount.
  • Only the copay or coinsurance amount, based on your benefit plan, after you've met the deductible amount.

Check your plan documents to see if you have a plan deductible and how it works with your benefit plan.

COMPREHENSIVE PHARMACY NETWORK

We have an extensive pharmacy network throughout the country, so it's easy to find a network pharmacy near your home or office.

Network pharmacies include major supermarket-based and privately owned pharmacies throughout California, as well as major pharmacy chains throughout the United States. When you fill your prescriptions at one of our network pharmacies, you receive your prescription drugs at the highest available benefit coverage under your plan. By using an out-of-network pharmacy, you may have to pay full price for your prescription.

Search for a network pharmacy

DRUGS: ENSURING A SMOOTH TRANSITION

Ensuring a smooth transition of your current drugs is an important first step for new members. You'll breathe easier knowing your current drugs are covered by your Health Net plan.

View our drug list to see if your drug is covered. Once you find it's on the list, you're good to go. If your drug requires prior authorization, you can either start the transition process or talk to your doctor about other drugs on our drug list that will work just as well for you.

How to transition your drugs
You can transition select maintenance drugs – those you take every day – to your new Health Net pharmacy coverage by following these simple steps:

  • Review the Prescription Transition form included in your enrollment packet.
  • A separate form is required for each family member transitioning drugs.
  • Make sure each drug you wish to transition, and which requires prior authorization, is listed on the form.
  • If your drug is not listed on the form, you may be required to have your doctor call us for prior authorization to ensure coverage.
  • The form(s) must be completed and submitted within the first three months of eligibility with Health Net.
  • Fax or mail the completed form(s) to the fax number or address shown on the form.

When we receive the form(s), authorization for each eligible drug will be entered into the pharmacy claims processing system, so you can obtain your drugs with your new Health Net pharmacy coverage.

If your doctor prescribes a drug that requires prior authorization, and is not on the Prescription Transition form or our drug list, your pharmacy will contact your doctor to either suggest an alternative drug covered by us and/or will ask your doctor to contact us to request coverage for the drug they prescribed. This is common practice followed by all pharmacies and doctors.

PRIOR AUTHORIZATION

If you're a new or existing Health Net member and your doctor orders a new drug, check to see if it is on our drug list and if it requires a prior authorization. If it does require a prior authorization (noted on the drug list with a "PA"), ask your doctor to contact Health Net to request coverage for the prescribed drug.

What is prior authorization?
Prior authorization is the process of getting approval from us for certain drugs before they are covered. This process is one of the ways we ensure our members get the safest drugs with the best value. We will approve prior authorization requests when medical necessity has been confirmed.

MAIL ORDER CONVENIENCE

Our mail order pharmacy program gives you the convenience of having your daily maintenance drugs delivered to your home or office. You also get the added benefit of receiving an extended supply of your prescription drugs. No need to think about refills every month. Our mail order pharmacy may also help you lower your out-of-pocket costs.

To fill out a Mail Order Pharmacy Form, click on a PDF below:

COST SAVING TIPS

Save time and money with these simple steps:

  • Ask your doctor about generic drugs that may work for you.
  • Fill prescriptions at our network pharmacies.
  • Be sure your doctor prescribes drugs on our drug list and ask if your drugs require prior authorization.
  • Fill your maintenance drugs through our mail order pharmacy program.

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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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Schedule of Benefits Disclaimer

This Schedule of Benefits is a brief list of benefits, with applicable copayments, coinsurance and deductibles information for your health plan. It does not list the exclusions and limitations or other important terms applicable to your plan.

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

The Evidence of Coverage (EOC) for your plan contains the complete terms and conditions of your Health Net coverage. It is important for you to thoroughly review the disclosure form and EOC for your plan, especially those sections that apply to those with special health care needs. You may view your Evidence of Coverage by: closing the current window and clicking on MY MEDICAL BENEFITS.

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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