The subscriber number can be found on your Health Net Insurance card. Please enter the complete ID, including all letters and numbers. All letters must be typed as capital letters.
Certain covered drugs require prior authorization. This means your doctor must have Health Net's pharmacy specialists review the prescription and approve it to obtain coverage. The prior authorization process insures that you are receiving the medication with the best value for your medical condition.
Your physician completes a Health Net Pharmacy Prior Authorization Form. Health Net will also accept the Medicare Part D Coverage Determination Request Form created by the American Medical Association. A member may initiate a request by submitting the Request for Medicare Prescription Drug Coverage Determination Form created specifically for members. All three forms can be accessed using the links at the end of this section. Completed forms should be faxed to: 800-977-8226.
If you or your physician do not have a fax machine, requests may be mailed to:
HNPS Prior Auth Department
10540 White Rock Road, Suite 280
Rancho Cordova, CA 95670
Upon receipt by Health Net, the request will be evaluated to determine if it meets standard approval criteria established by the Pharmacy and Therapeutics Committee. With this decision, we explain whether we will provide the prescription drug you are requesting or pay for a drug you have already received. If we deny your request (this is sometimes called an "adverse coverage determination"), you can "appeal" our decision by going on to Appeal Level 1 (see below).
We must respond to a request for an exception (including a formulary exception, an exception from utilization management rules - such as dosage or quantity limits or step therapy requirements - or a tiering exception), and make our decision no later than 72 hours after we have received your physician's "supporting statement," which explains why the drug you are asking for is medically necessary. In addition, you, any doctor, or your authorized representative can ask us to give a "fast" decision (rather than a "standard" decision) about Part D prescription drug coverage that you have not already received. If we give you a "fast" decision, we must make our determination as expeditiously as your health condition might require, but no later than 24 hours of receiving your request. For a "fast" decision, contact us by fax at the number above or by telephone at the number below:
Consult your Evidence of Coverage for specific coverages and limitations. The fact that a drug is listed on the Drug List does not guarantee that your physician will prescribe it for you for a particular medical condition. If you have questions about this procedure, please contact Customer Service at the numbers listed below.
Members should call:
|Health Net Orange (PDP):||800-806-8811, TTY/TDD 800-929-9955 (8 am - 8 pm, 7 days a week)|
Physicians should call: 800-867-6564
Pharmacy Prior Authorization Form - Medical Necessity (for physicians only)
Medicare Part D Coverage Determination Request Form (for physicians only)
Request for Medicare Prescription Drug Coverage Determination Form (for members only)
Information last updated 02/08/2011