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5 Things to Know about Rx Prior Authorization

5 Things to Know about Rx Prior Authorization

Have you ever wondered what the term "prior authorization" means in the context of prescription medications?

Prior authorization refers to the simple process of getting approval from Health Net for drugs that require pre-approval before they're covered by your Blue & Gold HMO plan from Health Net of California, Inc. (Health Net). It's one of the ways Health Net ensures you get the safest medications with the best value. It also helps us make sure you only ever receive pharmaceutical products that are approved by the Food and Drug Administration (FDA).

Here are five more things to know about prior authorization and prescription medications:

  1. You can review the list of drugs requiring prior authorization. All prescription medications that need prior authorization from Health Net are listed on Health Net's Recommended Drug List – also called the formulary – and noted by the initials "PA." Visit www.healthnet.com/uc > View My Blue & Gold Benefits > Pharmacy.
  2. Your doctor must contact Health Net to obtain prior authorization. If your doctor orders a new medication, you can check to see if it is on Health Net's Recommended Drug List and if it requires a prior authorization. If it does, ask your doctor to contact Health Net to request coverage for the prescribed medication. Or, your doctor can prescribe a medication that does not require pre-approval.
  3. It's easy to transition your medications that require prior authorization. If you're new to Health Net and you have an existing prescription for a medication that requires prior authorization, check if your medication is listed on our Prescription Transition Form. If it is, circle the drug and return the form to Health Net, and we will approve your medication. If your medication is not on the form, ask your doctor to contact Health Net to request coverage for the prescribed medication. The Prescription Transition Form can be found by going to www.healthnet.com/uc > Get Forms.
  4. The Health Net list is based on national guidelines. Health Net's list of drugs that require prior authorization is based on national guidelines and approved by our Pharmacy and Therapeutics Committee. We review it regularly and make updates where appropriate.
  5. There are different reasons why drugs require prior authorization. Medications that require prior authorization have a high potential for abuse; require laboratory tests or monitoring for safety reasons; are part of a step-care guideline; are used for indications not approved by the FDA or Health Net; and/or have a high potential for experimental use.

5 Things to Know about Rx Prior Authorization (pdf)

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