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Pharmacy FAQs for Medi-Cal Members

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Pharmacy FAQs

How do I find a network pharmacy?

For Medi-Cal members: Search the Pharmacy Locator to find a network pharmacy or call Customer Service. If your Pharmacy coverage is through Molina, use the Molina Healthcare Pharmacy Locator to find a network pharmacy.

I want to report wrong information on a Pharmacy listing.

If you found an error with a Pharmacy address or phone number, please Contact Us to report the issue.

What does "prior authorization" mean?

Some covered drugs require prior authorization or have coverage restrictions or limits. This means that you must receive approval from Health Net before the drug will be covered. If your doctor or pharmacist tells you that a prescription drug is not covered, or has coverage restrictions or limits, your doctor may request prior authorization or an exception.


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 drug has a quantity limit?

For some drugs, we only cover a specific amount of the drug. If a drug has a quantity limit, your doctor must request prior authorization for a higher amount to be covered.

Can I get an extra refill of drug if I'm going on vacation?

Yes. If your prescription is due while you're on vacation, we will cover an early refill once per year if you or your pharmacy lets us know. The refill is limited to a one month supply.

If I can't find my drug on the drug list, does that mean it's not covered?

Our drug lists are updated frequently. If you can't find your drug on our drug list, always Contact Us and ask if your drug is covered.

What is a compounded prescription?

A compounded drug is made by a pharmacist because the manufacturer does not make it in a certain strength or with certain ingredients. These prescriptions require prior authorization. Please Contact Us for questions about compounded drug coverage.

Who creates the Health Net Drug List?

Our drug list, or formulary, 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. Our drug lists are updated regularly and are subject to change. There is no guarantee that any specific drug included on the drug list 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 on prescriptions filled for emergency medical care. Please Contact Us for questions about reimbursements.

Are diabetic supplies covered?

Your 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 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:

Are generic drugs as safe as brand name drugs?

Yes. The United States Food and Drug Administration (FDA) requires that all drugs are safe and effective. Generic equivalent drugs use the same active ingredients as brand name drugs and work the same way.

Will the pharmacist give me a generic drug if one is available?

Yes. Network pharmacies may substitute a generic drug for a brand name drug if one is available. If the brand name drug is requested when a generic is available, your doctor must request prior authorization or an exception for it to be covered.

Are generic drugs as strong as brand name drugs?

Yes. FDA requires generic drugs to be equal to brand name drugs in quality, strength, purity, and stability.

Do generic drugs take longer to work in the body?

No. Generic 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 drugs?

Yes. Generic drugs will act the same way as brand name drugs. Be sure to discuss all the drugs you take with your doctor or pharmacist to ensure you have no adverse reactions.

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, FDA will not allow them to make drugs or be sold in the U.S.

Does every brand name drug have a generic equivalent?

No. New brand name drugs have a patent when they are first made. Most drug patents are protected for several years. The patent protects the company that originally made the drug. The patent does not allow another drug company to make and sell the drug. When the patent expires, other drug companies can start selling the generic version of the drug after it has been tested and approved by the FDA.

Why are generic drugs less expensive?

Developing a new drug is very expensive. Since generic drug companies do not develop a drug from scratch, the costs to bring the drug to market are less. Generic drug companies, however, must show that their drug acts 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 doctor choose a generic over a brand drug?

Generic drugs are proven to be safe, effective and typically cost much less than brand name drugs.

What is the best source of information about generic drugs?

Talk to your doctor or pharmacist for more information about generic drugs.

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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.


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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.


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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.


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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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