Prior Auth Protocol

Prior Authorization Protocol

Compounded Medications

NATL

Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.

FDA Approved Indications:
- N/A
Health Net Approved Indications and Usage Guidelines:
- Documentation of medical necessity over commercially available products, including preferred drug list agents
OR
- Pediatric dosing in the absence of commercially available products
AND
- The compound ingredients are FDA-approved
AND
- Medical literature support efficacy and safety for the intended use as defined in the members Evidence of Coverage
Coverage is Not Authorized For:
- Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
General Information:

Highest tier copay will be charged even if generic products are used
Therapeutic Alternatives:

Drug Dosing Regimen Dose Limit/ Maximum Dose
N/A
N/A
N/A
* Requires Prior Authorization
Recommended Dosing Regimen and Authorization Limit:

Drug Dosing Regimen Authorization Limit
N/A N/A
N/A
Product Availability:
N/A
References:

N/A

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
N/A	N/A	N/A

Drug	Dosing Regimen	Authorization Limit
N/A	N/A	N/A

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.