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Health Net Knowledge Base



PHARMACY

View our FAQs for answers to your pharmacy-related questions.


How do I use my Health Net pharmacy benefits?

Show your Health Net ID card at the pharmacy every time you get a prescription drug.

How do I find a network pharmacy?

Search the Pharmacy Locator to find a network pharmacy or call Customer Service.

How can I get the most from my pharmacy benefits?

When you have a prescription to fill, keep the following tips in mind:

  • Ask your doctor to prescribe generic drugs on our drug list.
  • If your drug is not available as a generic, or is non-preferred, ask your doctor to prescribe a brand-name drug on our drug list.
  • Take your drug list with you to doctor appointments.
  • Tell your doctor that you want to pay the lowest copayment possible for your drugs.

What does �prior authorization� mean?

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.

What do I do if my medication requires prior authorization?

If your drug requires prior authorization, talk to your doctor about other drugs for your condition that are on our drug list. If there are no other drugs, your doctor may request prior authorization for your drug from Health Net.

What does it mean if my medication has a quantity limit?

For certain drugs, Health Net limits the amount of the drug that Health Net will cover. If your drug has a quantity limit, your doctor must request prior authorization for a higher amount.

Can I get an extra refill of medication if I�m going on vacation?

Yes! If your prescription is due while you�re on vacation, an early refill can be made if you or your pharmacy notifies Health Net. You will be responsible for any additional copayment that may apply and will be limited to one additional month. If you need more than one month of refill, please use our mail order program (linked) to receive up to a three-month supply.

Does Health Net offer a mail order program?

Yes. Our mail order program (linked) is generally used for maintenance medications.

If my drug is not listed on Health Net�s Drug List, does that mean it�s not covered?

Our drug lists are updated frequently. If your drug is not on our drug list, call Customer Service and ask if your drug is covered.

What is a compounded prescription?

A compounded prescription is a medication that needs to be made by the pharmacist because the manufacturer does not make it in the prescribed strength or with the prescribed ingredients. These prescriptions may require prior authorization. Please call Customer Service for questions about compounded medications.

Who creates the Health Net Drug List?

Our formulary or drug list is a list of covered drugs selected by Health Net, along with a team of health care providers. These drugs are selected because they are believed to be a necessary part of a quality treatment program. Health Net covers both brand name and generic drugs. Our formulary is updated regularly, so make sure to look up your prescriptions before you choose a plan. There is no guarantee that any specific drug included on the formulary will be prescribed for a particular medical condition

Can I request reimbursement for pharmacy claims?

If you have paid out-of-pocket for a drug, you may be eligible for reimbursement (minus your copay) on prescriptions filled for emergency medical care.

How do I submit a claim for a pharmacy reimbursement?

Complete the Prescription Drug Claim Form and mail it with a copy of your detailed prescription receipts (not cash register receipts) to the address located on the form.

Claims must be submitted within one year of the date of service. If reimbursement is due to you, a check will be mailed within 30 days from when we received your claim.

AZ members:
Mail a copy of your prescription receipts (not cash register receipts) together with the member's name, Health Net ID number and daytime phone number to:
Health Net of Arizona
Attn: Pharmacy Dept.
5255 E. Williams Circle Suite 4000
Tucson, AZ 85711
Claims must be submitted within one year of the date of service. If a reimbursement is due to you, a check will be mailed within 30 days of our receipt of your claim.

OR & WA members:
Mail a copy of your prescription receipts (not cash register receipts) together with the member's name, Health Net ID number and daytime phone number to:
Health Net of Oregon
Attn: Pharmacy Claims
P.O. Box 10350
Van Nuys, CA 91410-0350
Claims must be submitted within one year of the date of service. If a reimbursement is due to you, a check will be mailed within 30 days of our receipt of your claim.

How are diabetic supplies covered?

The Health Net pharmacy benefit covers insulin, lancets, needles, syringes, and blood glucose test strips. Although these items are available over-the-counter, you must have a prescription in order for the pharmacy to process the claim.



Generic Drugs

What is a Generic Drug?

A generic drug is the same as a brand-name drug in:

  • Dosage, strength, safety, quality.
  • The way it works.
  • The way it is taken.
  • The way it should be used.

Are generic drugs as safe as brand-name drugs?

Yes. The FDA mandates that all drugs must be safe and effective. Generic equivalent drugs use the same active ingredients as brand-name drugs and work the same way. Therefore, they have the same risks and benefits as brand-name drugs.

Will the pharmacist dispense a generic drug if one is available?

Yes. Unless specifically told not to do so by you or your physician, pharmacies that contract with Health Net may substitute a generic drug for a brand-name drug. You should let your Pharmacists know if you want a generic equivalent.

Are generic drugs as safe as brand-name drugs?

Yes. The FDA mandates that all drugs must be safe and effective. Generic equivalent drugs use the same active ingredients as brand-name drugs and work the same way. Therefore, they have the same risks and benefits as brand-name drugs.

Will the pharmacist dispense a generic drug if one is available?

Yes. Unless specifically told not to do so by you or your physician, pharmacies that contract with Health Net may substitute a generic drug for a brand-name drug. You should let your Pharmacists know if you want a generic equivalent.

Are generic drugs as strong as brand-name drugs?

Yes. FDA requires that generic drugs be as high quality, strong, pure, and as stable as brand-name drugs.

Do generic drugs take longer to work in the body?

No. Generic equivalent drugs work in the same way and in the same amount of time as brand-name drugs.

Will generic drugs interact the same way as brand-name drugs with over-the-counter medications?

Yes. Generic equivalent drugs will behave in the same manner as brand-name drugs with the same interactions. Make sure to discuss all the medications you take with your physician, pharmacist or other health care professional to ensure you have no adverse reactions.

Also, by choosing a generic equivalent, you can save money through a lower copayment without compromising quality.

Are brand-name drugs made in better factories than generic drugs?

No. All factories must meet the same high standards. If the factories do not meet certain standards, the FDA will not allow their drugs to be sold in the U.S.

If brand-name drugs and generics have the same active ingredients, why do they look different?

In the U.S., trademark laws do not allow generic drugs to look exactly like the brand-name drug. Generic drugs are inspected by the FDA and must have the same active ingredients. Colors, flavors, and certain other ingredients may be different, but these differences should not affect the way the drug works.

Ask your physician if a generic drug if there is a generic equivalent drug that will be right for you.

Does every brand-name drug have a generic drug?

No. When new drugs are first made they are patented. Most drug patents are protected for 17 years. The patent protects the company that originally made the drug. The patent does not allow another manufacturer to make and sell the drug. When the patent expires, other drug companies can start selling the generic version of the drug, but they must first test the generic version of the drug and the FDA must approve it.

Why are generic drugs less expensive?

Developing a new drug is very expensive. Since generic drug makers do not develop a drug from scratch, the costs to bring the drug to market are less. Generic manufacturers, however, must show that their product performs in the same way as the brand-name drug. The FDA approves all generic drugs before they are released to the public.

Why would my physician choose a generic over a brand drug?

Generic drugs are proven to be safe, effective and typically cost much less than brand-name drugs. By choosing generic drugs, you can save money without compromising quality.

Who benefits when I choose a generic over a brand drug?

Everyone benefits from affordable health care, but we each must do our part to keep costs low. Using generic equivalents and generic alternatives whenever possible is an easy way to help keep your benefits affordable and receive the same quality of care.

Get into the habit of asking your physician if a generic equivalent or a generic alternative is available each time you are prescribed a medication. Be sure to share this important information with your family and friends, and ask them to do the same with you.

What are the immediate cost savings and long term cost savings when I choose a generic over a brand drug?

Immediate Cost Savings: Generally, generic equivalents or alternatives cost less and are available at a lower copay than the similar brand-name drugs.

Long Term Cost Savings: Choosing generic drugs helps keep health care costs lower for Health Net and our members, leaving valuable resources available for more critical needs.

What is the best source of information about generic drugs?

Contact your physician, pharmacist or other health care professional for information on your generic drugs.



PHARMACY (Medicare members)

View our FAQs for answers to your Medicare pharmacy-related questions.

How do I know if my drugs are covered?

You can search our Medicare Part D Formularies on the Drug Lists page. When it comes to benefits and prescription drugs, we are constantly re-evaluating our customers� needs. We know which conditions are most likely to affect you and the drugs you are most likely to need. That's why we've taken such care to ensure that our prescription drug plan for Medicare offers coverage for so many commonly prescribed, brand name, and generic drugs.

What if my drug is not on the Health Net Medicare Part D Formulary?

If you learn that Health Net does not cover your drug, you have two options:

  • You can talk to your prescriber about switching your prescription to a covered drug.
  • You can ask Health Net to make an exception and cover your drug.

How do I request an exception to the Health Net Medicare Part D Formulary?

There are several types of coverage determinations and exceptions that you can request. For more information about coverage determinations and exceptions, visit our Coverage Determinations pages:

How do I fill a prescription through Health Net�s mail order pharmacy?

View our Mail Order Overview page for general information about ordering your prescriptions by mail.

You can use the Health Net mail order pharmacy to fill prescriptions for most maintenance drugs that are on the Health Net Medicare Part D formulary. Some drugs may not be available through the mail order pharmacy. A maintenance drug is any prescription drug needed to treat a chronic or long-term condition.

When you order prescription drugs by mail, you may not order more than a 90-day supply of the drug at a time.

You are not required to use Health Net's mail order pharmacy to obtain an extended supply of your drugs. Instead, you have the option of using a retail pharmacy in Health Net's network to obtain an extended supply of your drugs. Some network retail pharmacies, however, will only dispense a maximum 30-day supply of drugs. To find out if your pharmacy will dispense an extended supply, check your pharmacy directory or ask your pharmacy.

How do I fill a prescription at an out-of-network pharmacy?

Before you use an out-of-network pharmacy, contact Customer Service to check if there is a network pharmacy in the area where you can fill your prescription.

If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

Generally, we will cover your prescription at an out-of-network pharmacy if you cannot reasonably be expected to obtain your drugs at a network pharmacy and when such access is not routine. This may include:

  • If you are unable to obtain a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide service 24-hours a day, seven days a week.
  • If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy (including high cost and unique drugs).
  • If you are getting a vaccine that is medically necessary but not covered by Medicare Part B or other covered drugs that are administered in your doctor's office.
  • If you need a prescription filled that is related to care for a medical emergency or urgent care.
  • If you are evacuated or otherwise displaced from your home because of a Federal disaster or other public health emergency declaration.
  • If you go to an out-of-network pharmacy, you may have to pay the full cost of your?drug rather than paying just your copayment. You can ask us to reimburse you for our share of the cost by submitting a claim. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy because any amount you pay will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described below.

How do I submit a paper claim?

Generally, when you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription and submit your claim and your prescription receipt to us. For more information on submitting a claim, visit our Claims Reimbursement pages:

How can I submit an appeal or complaint?

You have the right to make a complaint if you have concerns or problems related to your coverage or care. "Appeals" and "Grievances" are the two different types of complaints you can make. Which one you make depends on your situation. Appeals and grievances are discussed in the Evidence of Coverage. This information can be reviewed on our Appeals and Grievance pages:

What is the Health Net Medicare Part D Transition Program?

The Health Net Medicare Part D Transition Program allows eligible Health Net Medicare Part D members to receive a temporary supply of drugs to avoid disruption of therapy.

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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.

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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