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2-Tier Pharmacy Benefit
Health Net offers a prescription program with comprehensive drug coverage. Drug coverage is limited to drugs listed on this Drug List. The Drug List was developed by the Pharmacy and Therapeutics Committee, with involvement and recommendations from physicians, pharmacists, and other health care professionals. In addition to clinical considerations, the Committee evaluates the treatment costs of therapeutically equivalent pharmaceuticals. Development and maintenance of the Drug List is a dynamic process. The Drug List is continually reviewed and revised in response to recommendations from participating physicians and as new clinical data and pharmaceuticals become available.
The Drug List only applies to outpatient prescription drugs. It does not apply to inpatient drugs (hospital, skilled nursing facility or nursing home) or to drugs obtained from and/or administered by a health care professional.
Health Net offers a variety of prescription benefits. Drug coverage for plans with flat copay benefits (for example, $10 for generic drugs and $10 for brand name drugs) and 2-tier copay benefits (for example, $10 for generic drugs and $20 for brand name drugs) is limited to those drugs included on the Drug List. In addition, there are prior authorization requirements for select drugs on the Drug List. For these drugs and drugs not included on the Drug List, a physician may request a patient specific authorization. Requests for these drugs are evaluated to determine if the established approval criteria are met.
Under these benefits, prescriptions are filled with generic drugs when available. Unless otherwise indicated, if a brand name drug is dispensed when the generic equivalent exists, the amount charged is equal to the difference in cost between the generic and brand name drug, plus the brand name copayment. If a plan has a higher copayment for brand name drugs, and a brand name drug is dispensed when a generic equivalent does not exist, the brand name copayment will apply.
For more information regarding your pharmacy benefit, contact Health Net Customer Service at 1-800-289-2818. The TTY Customer Service number for the hearing impaired is 1-800-977-6757.