Pharmacy Prior Authorization
Some drugs require prior authorization. This means that members must receive approval from Health Net before a drug will be covered. Our drug lists identify which drugs require prior authorization.
To request prior authorization, the prescriber must complete and send us a Prior Authorization Form (pdf). We also require a supporting statement from the prescriber explaining why a particular drug is medically necessary for the member's condition.
Requests can be faxed or mailed to the contact information on the form.
Once we receive the prior authorization request, it is reviewed to determine if it meets our approval criteria. In this determination, we explain whether the request is approved or denied. If a request is denied, the member has the right to appeal our decision.
In some cases, step therapy is required before we will cover a drug. This means that members must try one drug before we will cover another drug for the same medical condition.
Example: if Drug A and Drug B both treat the same medical condition, we may not cover Drug B unless the member tries Drug A first. If Drug A does not work, we will then cover Drug B.
In the example above, if the member’s recent claims history shows use of Drug A, we will cover Drug B.
Health Net may override a step therapy requirement for some reasons. To ask for an override to a step therapy requirement, the prescriber must complete a Prior Authorization Form (pdf) and provide:
- A statement that the member tried and failed the step therapy drug(s). Or
- Medical justification about why the step therapy drug(s) are not appropriate for the member.
If a prescription drug is not covered, or there are coverage restrictions or limits on a drug, members or providers may request a coverage determination.
Members or providers can request a coverage determination to make an exception to our coverage rules. There are different types of exceptions that can be requested. An exception can be requested to:
- Cover a drug even if it is not on our formulary. Please note that if we grant a request to cover a drug that is not on our formulary, the drug will be available for the non-preferred brand tier copayment. The drug is not eligible for an exception for payment at a lower tier.
- Waive coverage restrictions or limits on a drug. For example, Health Net may limit the amount of a drug that will be covered. If a drug has a quantity limit, members can ask us to waive the limit and cover more.
- Cover a drug at a lower tier. Drugs on the preferred brand tier and Specialty tier may not be eligible for an exception for payment at a lower tier.
Generally, Health Net will only approve a request for an exception if preferred alternative drugs or utilization restrictions would not be as effective in treating the member's condition and/or would cause the members to have harmful medical effects.
Some drugs require prior authorization. This means that members must receive approval from Health Net before the drug will be covered. The prior authorization process ensures members are receiving the correct drug combined with the best value for their medical condition.
To request an exception or to obtain prior authorization, members or prescribers can email, fax or mail a coverage determination request to the contact information listed below. A coverage determination can also be requested by calling Customer Service. If a request is sent by email, it must include the member's name, Health Net member ID number and telephone number, as well as the details of the request. We also require a supporting statement from the prescriber explaining why a particular drug is medically necessary for the member's condition.
Once we receive the coverage determination request, it is reviewed to determine if it meets the requirements for approval. We must make our decision regarding an exception or prior authorization request and respond no later than 72 hours (24 hours for Medi-Cal covered drugs) after we have received the prescriber's supporting statement. Our response to the request will explain if the drug is approved to be covered. If we deny the request, members can appeal our decision. Information on how to file an appeal is included with the denial notification.
If waiting up to 72 hours for a "standard" decision could seriously harm the member's health or their ability to function, members or their prescribers can ask us to make a "fast" decision. A fast decision is sometimes called an expedited coverage determination and applies only to requests for Part D drugs that members have not already received. If a request for a fast decision is received, we must make our decision and respond within 24 hours. Requests for a fast decision can be made by fax or by calling Customer Service. We will make our decision and respond to all requests as quickly as the member's health condition requires.
Calls received after hours will be handled by our automated phone system and a Health Net representative will return the call on the next business day.
To protect personal health information and privacy, please do not send emails to Health Net using a personal email account.
Log in to the secure provider portal. Click on the blue "Message" icon at the top. Please attach any supporting or relevant documents to your secure email message.
For more information about coverage determinations, exceptions and prior authorization, refer to the plan's coverage documents or call Customer Service. The fact that a drug is listed on the formulary does not guarantee that it will be prescribed for a particular medical condition.